Do pathologic and molecular analyses of neck dissection specimens justify the preservation of level IV for laryngeal squamous carcinoma with clinically negative neck?

Since the first detailed description by Franciszek Jaw-dyn ́ski in 1888,1-4there have been many variations andmodifications of the radical neck dissection procedure.These include modified radical neck dissection (alsocalled functional neck dissection) and various selectiveneck dissections.5-6Analysis of the distribution of lymph node metastasesin patients with squamous carcinoma of the larynx re-veals a marked preference for levels II, III, and IV; levelsI and V are rarely involved.7-9Based on these observa-tions, lateral neck dissection has been recommended inpatients with necks staged as N0 or N1.10This meansremoving the upper jugular lymph nodes (level II), mid-dle jugular lymph nodes (level III), and lower jugularlymph nodes (level IV). Lateral neck dissection is alsodescribed as jugular node dissection by many surgeons.The need for routine dissection at level IV has re-cently been questioned.11This article discusses whethersparing level IV lymph nodes is justified on the strengthof pathologic and molecular studies on the pattern ofnodal metastasis in patients with squamous carcinomaof the larynx. In other words, dare we perform a selectiveneck dissection involving levels IIA and III for N0 necklaryngeal cancer to avoid potential complications such aschylous fistula or phrenic nerve injury