The staging and prognosis of oropharyngeal squamous cell carcinoma is intimately tied to the status of the cervical lymph nodes. Due to the high risk for occult nodal disease, most clinicians recommend treating the neck for these primary tumors. While there are many modalities available, surgical resection of nodal disease offers both a therapeutic and a diagnostic intervention. We review the relevant anatomy, nodal drainage patterns, clinical workup, surgical management and common complications associated with neck dissection for oropharyngeal squamous cell carcinoma. 1. Introduction Each year, 5000 new cases of oropharyngeal cancer are diagnosed in the US, and 85–90% of these are confirmed as squamous cell carcinoma (SCC) [1]. Cervical lymph node status remains the most important prognosticator in head and neck squamous cell carcinoma (HNSCC) in the absence of distant metastases, reducing 5-year survival by 50% [2, 3]. While the choice of management for occult metastases is complex, most clinicians agree that treatment should be chosen over observation when the risk of occult disease is 20% or greater [4]. The incidence of occult metastases in clinically node-negative necks (cN0) in OPSCC has been reported to be greater than 30% in some series [5, 6]. The importance of assessing and managing the cervical nodal basin in OPSCC is therefore of utmost importance and is the focus of the current paper. 2. Anatomy and Lymphatic Drainage of the Oropharynx Prognosis for patients with OPSCC is closely associated with the involvement of cervical lymph nodes. Therefore, an understanding of the anatomical subsites and lymphatic drainage patterns of each is crucial. The oropharynx is bounded by the posterior edge of the hard palate superiorly, the pharyngeal wall posteriorly, the tonsillar complexes (including the anterior and posterior tonsillar pillars, true tonsil, and tonsillar fossa) laterally, the circumvallate papillae and palatoglossal muscles anteroinferiorly, and the vallecula and hyoid bone inferiorly. The surgical anatomy of this area is classically divided into four distinct subsites: (1) base of tongue (BOT), (2) soft palate, (3) tonsillar complex, and (4) posterior pharyngeal wall (PPW) [7]. These subsites are independently important, and as Lindberg stated in his classic work on lymphatic drainage patterns in the head and neck, “metastases from primary lesions of the oropharynx have some common locales [8].” A thorough understanding of these drainage patterns is a prerequisite to the surgical neck dissection (ND) for OPSCC. 2.1. Base of Tongue The
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