Central Neck Dissection 
Mohamad Sidani, Salem I. Noureldine, José Gabriel Paixão 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
 
Central neck dissection is one of the pillars of 
treatment of thyroid cancer with lymphatic spread. 
The central neck compartment lymph nodes, also 
known as Level 6 and 7 nodes, are the most common 
(80%,) and first site of lymphatic spread of thyroid 
cancer.  
Regional lymph node metastases from 
differentiated thyroid cancer are present in the 
majority of patients with papillary thyroid cancer and 
medullary thyroid cancer, and in a smaller proportion 
of patients with other differentiated thyroid cancers 
such as Follicular thyroid cancer and Hürthle cell 
carcinoma. The presence of ymph node metastasis 
primarily affects most patients not through survival 
but by increasing the risk of subsequent nodal 
recurrence. 
The central neck is the gateway of the 
cervical lymphatic system and the “Delphian node” 
is the gatekeeper. It is located in the pre-cricoid or 
pre-laryngeal region. In addition to the Delphian 
node there are several other lymph node basins 
within the central neck: the pre-tracheal and the left 
and right para-tracheal lymph nodes.  
Metastases 
to 
the 
retropharyngeal 
or 
retroesophageal nodes are less common than to the 
more anterior lymphatics. Paralaryngopharyngeal 
lymph node involvement is rare, as the bulk of 
central lymph nodes are located inferior to the 
pharynx. Mediastinal lymph nodes located caudal to 
the brachiocephalic vein and adjacent to the tracheal 
bifurcation are rarely involved in patients with 
existing 
central 
compartment 
lymph 
node 
metastases. 
 
Central compartment borders: Hyoid bone (superior), superior 
border of innominate vein (inferior), common carotid arteries 
(lateral). This space contains prelaryngeal, pretracheal and 
right and left paratracheal lymph nodes. The Delphian node is 
circled in Red. McHenry CR, et al., used with permission. 
https://doi.org/10.1016/j.suc.2014.02.003  
 
 
Lastly, as the esophagus curves more to the 
left side of the neck, it creates a large empty space on 
the right posterior aspect of the trachea. This space 
will harbor numerous right paratracheal nodes that 
will be hidden deep to the right recurrent laryngeal 
nerve. These lymph nodes are commonly missed and 
hence are the most common site of thyroid cancer 
recurrence in the central neck.  
 
Right paratracheal lymph nodes are located deep to the right 
recurrent laryngeal nerve and are common site of cancer 
recurrence. Friedman et al., used with permission. 
https://doi.org/10.1016/j.otot.2011.04.001 
Central Neck Dissection 
Mohamad Sidani, Salem I. Noureldine, José Gabriel Paixão 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
To remove both the anterior and posterior 
lymph node compartments in this right paratracheal 
space, the right RLN needs to be transposed. The 
posterior compartment lymphatic tissue is then 
mobilized anteriorly and drawn under the nerve 
towards the lymph nodes that are caudal to the 
inferior thyroid artery. 
 
The anatomical borders of the central neck 
compartment are defined superiorly by the hyoid 
bone and inferiorly to the innominate artery on the 
right and the corresponding axial plane on the left. 
The compartment is bordered by the medial aspect of 
carotid sheath laterally. Its deep boundary is the 
prevertebral fascia.  
Border 
Surgical Anatomic landmark 
Superior 
Horizontal line at the inferior border of the 
cricoid and RLN insertion point 
Inferior 
The plane on level with the innominate 
artery 
Posterior 
Prevertebral fascia 
Anterior 
Sternothyroid muscle 
Lateral 
Common carotid artery 
Medial* 
Medial edge of contralateral strap muscles 
*In cases of unilateral central compartment neck dissection 
 
A comprehensive neck dissection implies 
comprehensive removal of the pretracheal and 
prelaryngeal lymph nodes, along with at least one 
paratracheal nodal basin. This operation can be 
unilateral or bilateral depending on whether one or 
both paratracheal regions are dissected.  
Focal “berry picking” of only involved LNs 
without a compartmental dissection leads to higher 
rates of recurrence and should not be done. The 
specific regions and nodal packets dissected as part 
of the comprehensive neck dissection should be 
clearly identified in the operative report. In addition, 
the indication for dissection should be defined as 
therapeutic or elective/prophylactic. A therapeutic 
dissection involves removal of clinically or 
radiographically apparent nodal metastases (cN1.) 
Conversely, prophylactic or elective neck dissection 
is the removal of clinically uninvolved nodes (cN0.)  
 
Indications for therapeutic central neck dissection 
are: 
1. cN1 disease for differentiated thyroid cancer 
(Papillary, Follicular or Hurthle cell carcinoma) 
a. Clinically palpable lymph nodes in the 
central neck compartment 
b. Obvious 
central 
compartment 
node 
involvement of neck ultrasound  
c. Biopsy proven central compartment node 
involvement (Fine Needle Aspiration is 
preferred.)  
2. Medullary thyroid cancer even in the absence of 
any clinical evidence of lymph node involvement. 
3. Central neck recurrence of thyroid cancer (if not 
already done in prior operations) 
 
The indications below for prophylactic central neck 
dissection remain a topic of debate: 
1. Older or very young patients (as they have a 
higher risk of at least microscopic lymph node 
involvement) 
2. T3 or T4 differentiated thyroid cancer without 
clinical evidence of central or lateral LN 
involvement (ie. extrathyroidal extension or 
invasion to surrounding structures and organs) 
3. Unfavorable histology (i.e tall-cell variant, 
diffuse sclerosing variant, or solid variant) 
4. Ipsilateral clinically apparent lateral neck disease 
(cN1b) is present and is being targeted with 
lateral neck dissection 
 
 
Most commonly a central neck dissection is 
performed at the time of total thyroidectomy. The 
thyroidectomy is performed first. Most surgeons will 
remove the thyroid specimen first and then remove 
the central neck nodes as one or 2 other specimens.  
In general, the steps of a central neck 
dissection are: 
• Dissection of the soft tissue anterior and medial 
to the common carotid artery from superior to 
inferior towards its insertion into the innominate 
artery or aortic arch 
• Dissection of the recurrent laryngeal nerve 
circumferentially all along its course distally 
from its insertion point into the cricothyroid 
muscle to the most visible caudal portion 
Central Neck Dissection 
Mohamad Sidani, Salem I. Noureldine, José Gabriel Paixão 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
• Separation of the soft tissue with the nodal basins 
en-bloc (preferably) from the trachea and 
esophagus and the underlying prevertebral fascia 
while making sure to identify and preserve the 
vascular pedicle to the inferior parathyroid 
glands, which are specifically placed at risk 
during this operation 
 
Steps: 
1. The patient is positioned supine with both arms 
padded and tucked and a shoulder roll placed 
under the shoulder blades as to extend the neck 
as much as possible with the head well supported. 
The “beach-chair” position should be used for 
additional extension if needed. Place sequential 
compression devices (if available) and consider 
administering a dose of preoperative antibiotics 
such as cefazolin.  
 
Patient in Semi-Fowler, also called “Beach Chair” position. 
Raising the head and torso like this decreases venous distention 
and bleeding. The surgeon must be cautious to avoid venous air 
embolism: in case of any injury to large veins, air can enter the 
venous system.  
 
2. Using a nerve monitor during this operation gives 
the following advantages:  
a. Its ability to map and localize the RLN 
and the external branch of the superior 
laryngeal nerve  
b. Its ability to aid in dissection once the 
nerves are identified  
c. In demonstration of mechanism and site 
of nerve injury 
d. Prognostication of postoperative nerve 
function allowing for intraoperative 
surgical decision changes to obviate 
bilateral nerve paralysis.  
If you plan on using a nerve monitor, 
the patient should not be paralyzed. If 
paralysis must be used for induction, you 
should favor a short-acting paralytic such as 
succinylcholine. If any other agent is used 
consider reversal of the paralytic agent to 
achieve 4 twitches of equal magnitude on 
“Train Of Four” monitoring using a 
peripheral nerve stimulator, prior to incision.  
 
In the more likely even that you do 
not have a nerve monitor, you must be 
meticulous about identifying the recurrent 
laryngeal nerve during the thyroidectomy and 
dissecting 
it 
carefully 
throughout 
the 
operation.  
 
Close-up of the endotracheal tube used with the nerve 
monitoring system with electrodes above the cuff that contact 
the vocal folds. These complete an electrical circuit, making an 
alerting sound, when the nerve monitor probe is touched to the 
recurrent laryngeal nerve in the neck. Source: Duran-Poveda 
MC et al, DOI: 10.5005/jp-journals-10002-1091  
 
3. If a nerve monitor is used, ensure the 
anesthesiologist uses a fiberoptic scope to 
intubate if possible, in order to confirm that the 
sensors on the endotracheal tube are spanning 
above and below the vocal cords.  
4. Ask for an esophageal temperature probe or an 
orogastric tube, as this assists in palpating the 
esophagus and finding the nerve more easily in 
the tracheoesophageal groove.  
Central Neck Dissection 
Mohamad Sidani, Salem I. Noureldine, José Gabriel Paixão 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
5. At this point proceed with the thyroidectomy 
portion of the procedure (See Chapter.)  
6. Once the thyroid is completely removed, re-
identify the recurrent laryngeal nerves bilaterally, 
and identify the parathyroid glands that were 
seen during the thyroidectomy. Assess their 
viability and associated vascular pedicles. The 
inferior parathyroid glands may be reflected 
away with their vascular pedicle allowing for 
paratracheal dissection and inferior parathyroid 
gland preservation.  If after dissection, the 
parathyroid gland appears nonviable and dusky, 
or there is interference with appropriate 
compartmental dissection, auto-transplant it. Cut 
it into small 1-2 mm pieces and then insert the 
pieces into several “pockets” of the ipsilateral 
sternocleidomastoid muscle. Loosely close the 
“pocket” to keep the pieces inside. 
7. Plan to start your central neck dissection on the 
side of the proven thyroid cancer first.  
8. Start your dissection by entering the avascular 
plane directly anterior/medial to the common 
carotid artery and develop that plane inferiorly 
down to the innominate artery. This can be done 
with a sealing energy device or bluntly. If an 
energy-sealing device is not available, use a 
bipolar rather than a monopolar diathermy. 
9. Next expose the anterior surface of the trachea at 
the level of the thyroid cartilage and dissect pre-
laryngeal and pre-tracheal tissue off of the 
tracheal rings using blunt dissection, if not 
already performed during thyroidectomy. Avoid 
using diathermy in this step, inadvertent entry 
into the trachea can cause a fire. Continue 
developing this plane all the way down until you 
reach the superior aspect of the innominate vein 
inferiorly.  
10. Next re-identify the recurrent laryngeal nerve 
and gently develop a plane over the nerve along 
its entire tract, proceeding cranially from its 
insertion into the cricothyroid muscle to the most 
caudal visible aspect of the nerve in your field of 
dissection. 
 
Steps 8-10, shown schematically on the left side on a neck after 
completed dissection, patient’s head is upwards in this picture. 
In Step 8, a plane is opened along the peri-adventital plane of 
the left common carotid artery. In Step 9, a plane is opened 
along the laryngeal and pre-tracheal tissue lateral to the 
midline of the trachea. In Step 10, tissue is elevated in between 
these two boundaries along the recurrent laryngeal nerve, 
proceeding from where the nerve inserts into the larynx in a 
caudal direction. Dissection is from cranial to caudal and 
lateral to medial, as described below.  
 
11. Dissect the soft tissue containing lymph nodes 
from the medial aspect of the carotid sheath 
moving from lateral to medial. Next transpose 
the nerve more laterally and proceed by excising 
all the soft tissue and lymph nodes medial and 
deep to the nerve. Continue this until you reach 
the trachea medially and the esophagus 
posteriorly. This should allow you to fully 
separate the central neck tissue and lymph nodes 
en bloc.  
Central Neck Dissection 
Mohamad Sidani, Salem I. Noureldine, José Gabriel Paixão 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Lateral view of the left central neck dissection, patient’s head 
is upwards in this picture. In this case, the central neck lymph 
node packet (Purple arrow) is being dissected as described, 
away from the left recurrent laryngeal nerve (Green arrow.) 
The left inferior parathyroid gland (Blue arrow) is seen and 
preserved. Note that in this case, the central node dissection is 
occurring prior to removal of the left thyroid lobe (Black arrow.) 
This is acceptable, but not described in this text.  
 
12. Continue dissecting this soft tissue/nodal bundle 
from the anterior and lateral aspect of the 
recurrent nerve down towards the innominate 
artery if possible.  
13. Be aware that the recurrent nerve can 
occasionally course anterior to the inferior 
thyroid artery, and sometimes it can bifurcate 
very 
proximal 
(more 
inferior) 
into 
an 
anteromedial motor branch and a posterolateral 
sensory branch.  
 
Photograph showing the relationship between the recurrent 
laryngeal nerve and the inferior thyroid artery (artery retracted 
by a Black suture). The artery may have a single or multiple 
branches, which may pass anterior or posterior to the nerve, or 
both. As the inferior thyroid artery is the blood supply of both 
the superior and inferior parathyroid glands, this relationship 
is especially Important. Source: Chintamani 
https://doi.org/10.1007/s12262-017-1691-2  
 
14. Prior 
to 
completely 
separating 
the 
soft 
tissue/nodal bundle near the inferior thyroid 
artery, makes sure you re-identify the parathyroid 
glands and their respective vascular pedicles and 
try to preserve them.  
 
Right sided tracheosesophageal groove after thyroidectomy, 
before neck dissection. The head is to the left of this picture. A 
pathologic lymph node is seen (Black arrow.) The right 
recurrent laryngeal nerve (Yellow arrow) is shown, with the 
expected anatomic relationship to the parathyroid glands. The 
superior parathyroid gland (Blue arrow) is dorsal/posterior to 
the nerve and the inferior parathyroid gland (Green arrow) is 
ventral/anterior to the nerve. Note that the pathologic lymph 
node is darker than the parathyroid glands, and “kidney bean” 
in shape compared to the parathyroid glands.  
 
Central Neck Dissection 
Mohamad Sidani, Salem I. Noureldine, José Gabriel Paixão 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
15. Do not forget to examine on the right side the 
space deep to the inferior thyroid artery and 
recurrent nerve as it can harbor several lymph 
nodes. This is actually the most common location 
of central neck recurrence in thyroid cancer, as 
discussed in the Introduction.  
 
Lateral view of the right central neck, head is upwards in this 
picture and midline is on the right side of the photo. The Blue 
arrow shows the deep level 6 cervical lymph node packet (that 
is not present on the left side.) These nodes are located deep to 
the right recurrent laryngeal nerve (Green arrow) and anterior 
to the esophagus (though they have been mobilized anterior to 
the nerve in this photo.) These nodes are a common area of 
tumor recurrence as they can be easily missed.  
 
 
Another view of the same patient, right central neck, head is 
upwards in this picture. The Blue arrow shows the deep level 6 
cervical lymph node packet, located deep to the right recurrent 
laryngeal nerve (Green arrow) and anterior to the esophagus 
(Purple arrow.) 
 
 
16. Examine the specimen after removal for any 
parathyroid tissue. In resource-rich settings, 
surgeons confirm the tissue in question is indeed 
parathyroid tissue using frozen section before 
auto-transplanting, to avoid implanting a lymph 
node containing cancer. If you do not have frozen 
section capabilities, follow the principles 
described above to preserve as many viable well 
vascularized parathyroid glands in-situ as 
possible.  
Central Neck Dissection 
Mohamad Sidani, Salem I. Noureldine, José Gabriel Paixão 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Completed central neck dissection shows the inferior boundary 
of dissection, the innominate artery (Black arrow) and the right 
lateral boundary of dissection, the common carotid artery 
(White arrow.) A preserved parathyroid gland (White circle) is 
also seen.  
 
17. At the end re-assess the recurrent nerve by 
following its course entirely. Assess its function 
if you are using a nerve monitor.  
18. Obtain meticulous hemostasis. Avoid using the 
“pinch buzz” technique (i.e. holding tissue, 
including possibly near the nerve, and touching 
the forceps with the monopolar diathermy.) 
Sometimes gentle pressure and irrigation with 
sterile water is all that is needed. Use ties or clips 
instead of an energy device. Any bleeding along 
the trachea can be stopped with mindful use of 
the bipolar diathermy. If there is slow oozing 
adjacent to the recurrent laryngeal nerve, it is 
better to leave this rather than pursue a “scorched 
earth” tactic with the diathermy. Pulsatile 
bleeding adjacent to the nerve, on the other hand, 
is a branch of the inferior thyroid artery and must 
be controlled with a carefully applied vascular 
clip or clamp and ligature. 
19. Irrigate with sterile water and ask the anesthetist 
to perform a Valsalva maneuver (up to 30 mmHg) 
to check for any bleeding. Lastly consider 
placing a topical hemostatic agent along the bed 
of dissection (Gel foam cut into small squares 
soaked in thrombin, or surgical nitrocellulose.) 
20. Close the wound in multiple layers like you 
would for a thyroidectomy. Usually leaving a 
drain is not required in central neck dissections, 
unless a large substernal goiter requiring 
extensive dissection was concomitantly removed. 
This decision is surgeon dependent, and 
outcomes are not different with or without a drain.  
21. Administer oral calcium carbonate 1500mg three 
times per day for the first two weeks after surgery 
and then wean this amount as the patient tolerates. 
Be 
mindful 
of 
hypocalcemia 
symptoms, 
including perioral numbness, cramping in the 
hands, and laryngospasm.  
 
Pitfalls 
• Try to set your self up for success by optimizing 
your neck extension, and by placing an 
esophageal temperature probe to help locate the 
esophagus, and therefore the tracheoesophageal 
groove, early during dissection.  
• It is helpful to know the different anatomical 
trajectories of the recurrent nerve on the right the 
left side. On the right the nerve is more anterior 
and oblique in its course, and on the left the nerve 
is deeper, more medial and more vertical as its 
coursing in the tracheoesophageal groove. 
• Be aware of the rare non-recurrent right laryngeal 
nerve (it is exceedingly rare to encounter a non-
recurrent laryngeal nerve on the left.) This is 
commonly 
associated with aberrant right 
common carotid and right subclavian artery 
anatomy. One way to predict that is using 
intraoperative ultrasound, if available, pre-
incision. If you see that the right subclavian 
artery and right common carotid artery do not 
merge at the base of the neck, it is highly likely 
you have a non-recurrent nerve. If you have  
preoperative cross-sectional imaging (CT scan,) 
an aberrant right subclavian artery with a 
retroesophageal course is highly predictive of a 
right non-recurrent laryngeal nerve. 
Central Neck Dissection 
Mohamad Sidani, Salem I. Noureldine, José Gabriel Paixão 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Aberrant right subclavian artery with a retroesophageal course 
(Red arrow) in a patient that was found to have a right non-
recurrent laryngeal nerve.  
 
• Use of a nerve monitor can help you assess not 
only the location and structural integrity of the 
nerve but its function as well. It can occasionally 
help guide the decision to proceed to the 
contralateral side and subsequently avoid 
bilateral recurrent nerve injury and airway 
compromise. Always know that a nerve injury 
comes in different shapes and forms, ranging 
from a grasping injury, to a traction injury, to a 
partial or 
complete transection. A non-
transection injury is potentially one that a patient 
can recover from. A nerve monitor can help 
identify those injuries, as a nerve will structurally 
look intact in those cases. 
• If you realize that one nerve was injured, 
consider abandoning any dissection (whether 
thyroidectomy or central neck dissection) on the 
contralateral side during the same operation, as 
you can always come back to “fight another day.” 
Usually, you can wait 6 weeks and the re-assess 
the function of nerve and vocal cords in clinic, 
using either ultrasound or flexible laryngoscopy, 
prior to planning a completion thyroidectomy or 
central neck dissection. 
• Realize that a nerve monitor will not prevent an 
injury it will only help identifying and 
recognizing it earlier. 
• Postoperative hypocalcemia can occur after even 
the most meticulous surgical technique. In most 
cases the parathyroid glands are not permanently 
damaged; they are “stunned” from the adjacent 
dissection. You may need to supplement calcium 
at 
high 
doses 
after 
surgery, 
including 
intravenously. Once the patient is stable 
clinically with oral calcium supplementation 
only, it is safe to discharge them on this dosage, 
maintain it for two weeks, and then taper the 
dosage as an outpatient under close supervision.  
 
Mohamad Sidani MD 
Texas Tech University Health Sciences Center 
Lubbock, Texas, USA 
 
Salem I. Noureldine MD 
George Washington University Hospital 
Washington, DC, USA 
 
José Gabriel Paixão 
University Hospital João de Barros Barreto 
Belém, Pará, Brazil 
 
April 2023 
 
 
