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Updated: Jul 15, 2026
Modified Radical Neck Dissection for Cervical Metastasis
Published on: February 20, 2026
Is Level IIB Dissection Necessary in the Clinically N0 Neck? A Systematic Review and Meta-Analysis in Head and Neck
Matteo Fermi1, Francesco Chiari2, Gerardo Petruzzi3
1Department of Otorhinolaryngology-Head and Neck Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum Bologna, Bologna, Italy.
Background:
The management of sublevel IIB during elective neck dissection (END) for clinically node-negative (cN0) head and neck squamous cell carcinoma (HNSCC) remains debated. Although level IIB metastases are considered uncommon, omission of this sublevel must be balanced against the risk of undertreating occult node metastasis and the potential morbidity related to spinal accessory nerve (SAN) manipulation.
Methods:
A systematic review was conducted according to PRISMA 2020 guidelines. Embase, PubMed, Scopus, and Cochrane Library were searched for studies published until April 30, 2026. Eligible studies included adult patients with cN0 laryngeal (LSCC), oral cavity (OCSCC), oropharyngeal (OPSCC), or hypopharyngeal squamous cell carcinoma (HSCC) undergoing END with level-specific pathological assessment, including sublevel IIB. A random-effects meta-analysis of proportions was performed to estimate the pooled prevalence of level IIB metastases by tumor subsite.
Results:
Thirty-five studies were included. The pooled prevalence of level IIB metastasis was 1.7% for LSCC, 1.2% for OCSCC, 2.6% for OPSCC, and 2.5% for HSCC. Across subsites, level IIB showed consistently lower metastatic involvement than adjacent nodal levels. In LSCC and OCSCC, exploratory study-level stratification suggested persistently low level IIB involvement even in cohorts enriched with advanced-stage tumors. SAN-related morbidity was inconsistently reported, with available studies showing rates up to 4%, and postoperative shoulder impairment reported in up to 2% of dissections.
Conclusions:
Level IIB demonstrates a consistently low prevalence of occult metastasis in cN0 HNSCC, particularly in LSCC and OCSCC. These findings suggest that routine level IIB dissection may not be necessary in carefully selected low-risk patients. Surgical decision-making should be individualized according to tumor subsite, stage, and intraoperative findings.
