Management of the neck in squamous cell carcinoma of the upper aerodig
estive tract continues to be a topic of great debate. One major proble
m is that incorrect clinical staging is expected in approximately 20%
of necks. This is true of both clinical stage NO and N+ necks, even wh
en imaging studies are used. This prospective study of 108 necks in 79
patients examined the role of intraoperative palpation and inspection
in improving the surgeon's ability to predict nodal stage, Of 62 pati
ents with NO necks clinically on both sides, 26 were staged N+ by intr
aoperative node examination, Nineteen of the 26 were histologically ne
gative (73% false-positive). Of the 36 patients staged intraoperativel
y as NO, 10 were histologically positive (28% false-negative). Of 108
necks judged clinically to be NO, 25 (23%) had occult metastases and 1
1 (10%) had extracapsular spread. Forty-one of 108 clinical NO necks w
ere believed to have positive nodes at the time of neck dissection. Of
these 41 necks, 30 (73%) were found to be histologically NO (false-po
sitive). Of the 67 clinical NO necks that were also believed to be NO
intraoperatively, occult metastases were found in 14 (21% false-negati
ve). Therefore, intraoperative staging did not significantly improve t
he false-negative rate. Frozen-section biopsy obtained in the operatin
g room was reliable in 24 (92.3%) of 26 patients. Although frozen-sect
ion biopsy was not performed in all patients, these data suggest that
upstaging the neck without frozen-section biopsy is much less reliable
. This study supports the use of frozen-section biopsy before converti
ng the selective dissection to a radical or modified neck dissection i
n most instances.