text:
TITLE: Neck Dissection:
Classification, Indications and Techniques
SOURCE: Grand Rounds Presentation, UTMB, Dept. of Otolaryngology
DATE: January 16, 2002
RESIDENT PHYSICIAN: Christopher D. Muller, M.D.
FACULTY PHYSICIAN: Shawn Newlands, M.D., Ph.D.
SERIES EDITORS: Francis B. Quinn, Jr., MD and Matthew W. Ryan, MD
[ Grand Rounds Index | UTMB Otolaryngology Home Page ]
"This material was prepared by resident
physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the
UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended
for clinical use in its present form. It was prepared for the purpose of
stimulating group discussion in a conference setting. No warranties, either
express or implied, are made with respect to its accuracy, completeness, or
timeliness. The material does not necessarily reflect the current or past
opinions of members of the UTMB faculty and should not be used for purposes of
diagnosis or treatment without consulting appropriate literature sources and
informed professional opinion."
The single most prognostic factor for patients with squamous carcinomas of the upper aerodigestive tract is the status of the cervical lymph nodes. Cure rates drop to nearly half when there is involvement of regional lymph nodes.
The first conceptual approach for removing nodal metastases was made by Kocher in 1880. The classic technique of the radical neck dissection was later described by George Crile in 1906. Originally, this technique included removal of the submandibular salivary gland, internal jugular vein, greater auricular and spinal accessory nerves, as well as the digastric, stylohyoid, and sternocleidomastoid muscles. It was later popularized by Blair (1933) and Martin (1941) and the technique has remained virtually unchanged since. Martin believed in the concept that cervical lymphadenectomy for cancer was inadequate unless all the lymph-node-bearing tissues of one side of the neck were removed. This, he felt, was impossible without the removal of the spinal accessory nerve, the internal jugular vein, and the sternocleidomastoid muscle.
The 1960s and 70s marked a significant change in the attitude towards the surgical treatment of head and neck malignancies. This change was exemplified by the evolution of conservation laryngeal surgery where preservation of tissue and function was considered in the development of new surgical techniques and treatment. Similarly, this attitude began to infiltrate those developing new therapeutic modalities for the treatment of the neck. In 1953, Pietrantoni, a strong advocate of bilateral elective neck dissection, recommended sparing the spinal accessory nerves and at least one internal jugular vein. This break with surgical tradition was first limited to elective neck dissections, but was later extended to therapeutic dissections when lymph nodes were enlarged but still mobile. In 1967 Bocca and Pignataro described an operation that removed all of the lymph node groups but spared the sternocleidomastoid muscle, the spinal accessory nerve, and the internal jugular vein. Bocca, a staunch opponent of conservative nodal stripping indicated the complete effectiveness of his surgical technique, which he described in the Semon Lecture to the Royal Society of Medicine in 1975: "a complete dissection of the lateral cervical space, anatomically confined by a fascial envelope, and itself containing the major cervical lymphatics". He called this technique the "functional neck dissection". He followed nearly 400 patients with N0-N2 treated with this technique. These patients showed no difference in survival from those patients treated with radical neck dissection. Since this time a multitude of modified techniques have evolved to more specifically address early stage neck metastases. In 1989, Medina suggested that lymphadenectomies be categorized as comprehensive, selective, or extended. Robbins et al. in 1991 used the term "selective" to distinguish patients who had one or more nodal groups preserved. Although these modifications have refined surgical treatment of the neck, it has also resulted in a nomenclature system that is confusing and non-uniform. In response to this confusion, in 1991 Robbins et. al. published the Official Report of the Academy's Committee for Head and Neck Surgery and Oncology standardizing neck dissection terminology. This terminology was adopted by the American Academy of Otolaryngology-Head and Neck Surgery and is the current terminology used by the American Joint Committee on Cancer (1997). To date there is continued debate and discussion as to the indications for these different neck dissections in treatment of the neck for various types and stages of head and neck malignancies.
A firm grasp of the applied and basic anatomy of the neck is paramount in providing appropriate surgical treatment to patients with head and neck cancer. Below is thorough, but by no means exhaustive, discussion of the anatomic structures that must be considered when performing a neck dissection.
Platysma Muscle
Origin and insertion. The platysma muscle is a broad sheet of muscle arising from the fascia covering the upper parts of the pectoralis major and deltoid muscles and contained in the superficial cervical fascia; its fibers cross the clavicle, and proceed obliquely upwards and medially in the side of the neck. The anterior fibers interdigitate, with the fibers of the opposite muscle below and behind the mental symphysis; succeeding fibers insert into the lower border of the body of the mandible more anteriorly while more laterally and posteriorly they cross the mandible and insert into the skin and subcutaneous tissue. Particularly in the area of the corner of the mouth the platysma interdigitates with the facial musculature.
Nerve supply. The platysma is innervated by the cervical branches of the facial nerve.
Function. The platysma muscle has four functions: (1) it wrinkles the surface of the skin of the neck in an oblique direction, and diminishes the concavity between the jaw and the side of the neck; (2) assists the facial muscles of expression in depressing the angle of the mouth; (3) increases the diameter of the neck during rapid respiration; (4) assists with venous return by increasing negative pressure in the superficial veins of the neck.
Surgical considerations. Raising skin flaps during a neck dissection is carried out in a subplatysmal plain. The purpose of this technique is to provide better blood supply to the flap. Laterally the fibers of the SCM may be confused for the platysma. The fibers of the platysma run anterosuperiorly from its origin while the fibers of the SCM run posterosuperiorly.
Sternocleidomastoid Muscle (SCM)
Origin and insertion. The SCM passes obliquely in the neck forming an "X" with respect to the more superficial fibers of the platysma muscle. It is invested in the superficial layer of the deep cervical fascia. It consists of two heads, one that originates from the medial third of the clavicle (clavicular or lateral head) and another which originates from the manubrium sterni (sternal head). These two join together and insert onto the mastoid process of the temporal bone.
Nerve supply. The SCM is innervated by the spinal accessory nerve (CN XI). The entire nerve may traverse the muscle. It also receives proprioceptive innervation by cervical spinal nerves from the cervical plexus
Blood supply. There are three sources of blood supply to the SCM: (1) the occipital artery or directly from the external carotid artery, (2) the superior thyroid artery, and (3) the transverse cervical artery
Function. When one SCM contracts, the head rotates away from the side of the contracting muscle and tilts towards the ipsilateral shoulder. Both muscles are act together against gravity to draw the head forwards and help to flex the cervical part of the vertebral column. This is a common movement in feeding. If the head is fixed, they assist in elevating the thorax in forced inspiration.
Surgical considerations. (1) When raising skin flaps care should be taken to leave the superficial layer of deep cervical fascia overlying the SCM down. This will later be the dissection plain for unwrapping the SCM and will provide attachment to the contents of the posterior triangle for en bloc resection. (2) firm lateral retraction near the superior aspect of the SCM and upwards retraction on the mandible allow for good exposure in locating the spinal accessory nerve and in dissection of lymph nodes in the submuscular recess.
Omohyoid muscle
Origin and insertion. The omohyoid muscle consists of two bellies (inferior and superior). The inferior belly arises from the upper border of the scapula near the scapular notch. From there it inclines forward and slightly upwards across the lower part of the neck dividing the posterior triangle into an upper, occipital and lower, supraclavicular triangle. It passes deep to the SCM and ends in the intermediate tendon, which usually lies adjacent to the internal jugular vein, opposite the arch of the cricoid cartilage. This tendon is ensheathed by a band of deep cervical fascia, which is attached to the clavicle and first rib and is responsible for the angled appearance the inferior belly makes with the superior. The superior belly extends from the intermediate tendon and passes nearly vertically close to the lateral border of the sternohyoid muscle and attaches to the lower border of the hyoid bone lateral to the insertion of the sternohyoid muscle.
Nerve supply. Nervous innervation to the omohyoid muscle comes from branches of the ramus superior of the ansa cervicalis (C1-C3).
Blood supply. Inferior thyroid artery
Function. The omohyoid depresses the hyoid bone after is has elevated during swallowing. It is speculated that it tenses the deep cervical fascia during deep inspiration to prevent collapsing of soft tissues.
Surgical considerations. The omohyoid may be absent in 10% of individuals. It is a useful landmark when dissecting the level IV lymph nodes. The inferior belly lies superficial to the brachial plexus, phrenic nerve and transverse cervical vessels. The superior belly lies just superficial to the internal jugular vein.
Trapezius Muscle
Origin and insertion. The trapezius is a flat sheet of muscle extending over the back of the neck and upper thorax. It originates from the medial one-third of the superior nuchal line of the occipital bone, the external occipital protuberance, the ligamentum nuchae, the seventh cervical and all the thoracic vertebral spinous processes, and the corresponding supraspinous ligaments. The upper fibers extend inferiorly and laterally, the middle fibers laterally, and the inferior fibers superiorly and laterally to join laterally and insert into the shoulder at the lateral third of the clavicle, the medial margin of the acromion and the spine of the scapula.
Nerve supply. Nervous innervation to the trapezius muscle is provided by the spinal accessory nerve.
Function. The trapezius functions to elevate and rotate the scapula forward and assists in elevating the arm above the head. It also stabilizes the shoulder when the arm is loaded.
Digastric Muscle
Origin and insertion. The digastric muscle has two bellies, anterior and posterior. The anterior belly originates from the digastric fossa of the mandible (at the symphyseal border). It extends inferiorly and lateral superficial to the mylohyoid muscle to the hyoid bone where it unites with the posterior belly via an intermediate tendon. The intermediate tendon perforates the stylohyoid muscle and is held to the side of the body and the greater cornu of the hyoid bone by a fibrous loop. The posterior belly is longer than the anterior belly. It extends posteriorly and inserts into the mastoid process
Nerve supply. The anterior belly is supplied by the mylohyoid branch of the inferior alveolar nerve (V3). The posterior belly is innervated by the facial nerve.
Function. The action of the digastric muscle is to depress the mandible and can elevate the hyoid bone. EMG studies indicate that both bellies act together and are secondary to the lateral pterygoid in mandibular depression, coming into play especially in maximal depression.
Surgical considerations. The digastric is often referred to as the "residents friend". It is named so because many vital structures may be avoided by dissecting lateral to it. The posterior belly lies directly superficial to the branches of the external carotid artery, the hypoglossal nerve, the internal carotid artery, and the IJV. The spinal accessory nerve crosses over the IJV and immediately deep to the digastric in 70% of patients. The anterior belly is also a good landmark. Dissection of fascia and nodes just posterior to it helps in identification of the mylohyoid muscle and ensures safe dissection of the submandibular triangle.
Marginal Mandibular Nerve (ramus mandibularis)
Preserving the marginal mandibular branch of the facial nerve is important component of a neck dissection. It is most commonly injured when dissecting the level Ib lymph nodes in the submandibular triangle. The nerve extends proximally from the lower division of the facial nerve through the parotid gland and can be located at the mandibular notch about one centimeter anterior and inferior to the angle of the mandible. It lies deep to the fascia covering the submandibular gland (superficial layer of the deep cervical fascia) but superficial to the adventitia of the anterior facial vein. Preservation of the nerve may be accomplished by ligating the anterior facial vein low in the submandibular triangle and retracting it superiorly but this may result in elevation of the prevascular and retrovascular lymph nodes. This practice should therefore be restricted to non-oncologic surgery in this area. From the submandibular gland the nerve extends superiorly into the platysma muscle and depressors of the mouth. There is usually more than one branch present, which may loop inferior to the gland. Sensory branches may also travel with the marginal mandibular nerve but continue inferiorly and must be sacrificed with the neck dissection.
Spinal Accessory Nerve
The spinal root of the accessory nerve is a union of motor neurons whose cell bodies originate in the spinal nucleus located in the anterior grey column of the spinal cord. It may extend downwards as low as the fifth cervical segment. They emerge from the spinal cord on its surface midway between the ventral and dorsal nerve roots of the upper cervical nerves and from there join to form one trunk which travels superiorly through the foramen magnum, behind the vertebral artery. It then exits the skull via the jugular foramen. In approximately 70% or cases the nerve passes lateral and posterior to the internal jugular vein (IJV). In 30% of cases it passes medial to the vein and in rare cases (3-5 %) the nerve splits the IJ. The nerve then crosses the transverse process of the atlas and is, itself, crossed by the occipital artery. It descends obliquely through the level 2 lymph nodes medial to the styloid process, the stylohyoid muscle, and the posterior belly of the digastric. It then penetrates the deep surface of the SCM giving off a branch to it. It exits the posterior aspect of the SCM deep to Erb's point (point where the greater auricular nerve wraps around and crosses the SCM) and traverses the posterior triangle (Level V) lying on the levator scapulae, from which it is separated by the prevertebral layer of deep cervical fascia. Approximately 5 cm above the clavicle, the accessory nerve disappears under the anterior border of the trapezius.
Brachial Plexus and Phrenic nerve
The brachial plexus is formed by the union of the ventral rami of the lower four cervical nerves and the greater part of the ventral ramus of the first thoracic nerve (C5-8 and T1). In the neck it lies in the inferior aspect of the posterior triangle in the angle between the clavicle and the lower part of the posterior border of the SCM. It enters the posterior triangle between the anterior and middle scalene muscles along with the subclavian artery which lies anterior and inferior to it. The plexus is crossed by the supraclavicular nerves, the nerve to the subclavius, the inferior belly of the omohyoid, the external jugular vein and the transverse cervical artery.
The phrenic nerve provides the sole innervation to diaphragm. It is comprised of fibers from cervical roots 3-5. It runs obliquely toward the midline along the anterior surface of the anterior scalene muscle and is covered by prevertebral fascia. The vagus nerve and the sympathetic trunk should not be confused for the phrenic nerve. The vagus lies anterior to the phrenic in the posterior aspect of the carotid sheath and the sympathetic trunk lies medial and posterior to the carotid sheath. Neither crosses over the anterior scalene. When transecting cervical rootlets as is routine in neck dissections, it is important to cut distal to their contributions to the phrenic. This can be accomplished by identifying the cervical nerves as they exit the plexus, and then transect them high on the specimen.
Hypoglossal Nerve
The hypoglossal nerve is the motor nerve of the tongue. Its cell bodies originate in the hypoglossal nucleus in the medulla oblongata. The nerve exits the skull via the hypoglossal canal of the occipital bone. As it exits the canal it lies deep to the IJV, the internal carotid artery, and CN IX, X, and XI. It passes laterally and inferiorly behind the internal carotid artery and the glossopharyngeal and vagus nerves to gain the interval between the artery and the IJV. At this point, it is surrounded by numerous veins forming a venous plexus called the ranine veins. It then makes a half-spiral turn round the inferior ganglion of the vagus, to which it is united by connective tissue. It then descends almost vertically becoming more superficial below the posterior belly of the digastric. It loops round the inferior sternocleidomastoid branch of the occipital artery and crosses the loop of the lingual artery a little above the tip of the greater cornu of the hyoid bone. It is crossed here by the facial vein. It extends upwards along the hyoglossus muscle and into the genioglossus traveling in its substance as far as the tip of the tongue.
The hypoglossal nerve is most commonly injured during inappropriate dissection of the floor of the submandibular triangle where is lies just deep to the submandibular duct. It may also be injured by inadvertent clamping while controlling bleeding veins in the plexus posterior and inferior to the posterior belly of the digastric muscle.
Thoracic Duct
The thoracic duct conveys the greater part of the lymph back into the circulating blood. It drains lymph from the entire body except for the right side of the head and neck, the right upper extremity, right lung, right heart, and part of the convex surface of the liver. The duct proper begins at the upper end of the cisterna chyli near the lower thorax through the aortic opening of the diaphragm. It then ascends through the posterior mediastinum with the aorta on its left and azygos vein on its right. The duct begins to course toward the left and enters the superior mediastinum, and ascends to the thoracic inlet along the left side of the esophagus. As the duct passes into the neck it lies anterior to the vertebral artery and vein, the sympathetic trunk and the thyrocervical trunk. It is separated from the phrenic nerve by the prevertebral fascia. Finally it descends in front of the first part of the left subclavian artery and ends by opening into the junction of the left subclavian and internal jugular vein. It may enter the distal IJV as well. It may be a single large duct of break up into a variable number of smaller vessels just prior to its termination.
It is important to remember that there is a smaller lymphatic duct in the right neck. It descends along the medial border of the anterior scalene and ends by opening into the junction of the right subclavian and internal jugular veins.
The preferred method to prevent chyle leak is the en bloc ligation of the lymphatic pedicle in which the lymphatic ducts lie. This should be done only after the carotid artery, vagus, phrenic, and IJV or identified. A leak may be difficult to detect, as chyle is not milky colored in the fasting individual. Microscopic examination may be of benefit if a leak is suspected. Having the anesthesiologist Valsalva the patient at this time may increase the flow of chyle from a leaking duct facilitating its discovery.
Lymph Node Levels/Nodal regions
For ease and uniformity of description, nodal regions have been subdivided into levels with corresponding clinical descriptions. This system was established by the Sloan-Kettering Memorial Group and is as follows:
Level I: Lymph node groups – submental and submandibular
Level Ia*: Submental triangle
Boundaries – anterior bellies of the digastric muscle and the hyoid
Level Ib*: Submandibular triangle
Boundaries – body of the mandible, anterior and
posterior belly of the digastric muscle
Note: includes the submandibular gland, pre- and postglandular
lymph nodes and pre- and postvascular (relative to facial vein
and artery) lymph nodes
Note: does not include perifacial lymph nodes
Level II: Lymph node groups – upper jugular
Boundaries – 1) anterior – lateral border of the sternohyoid muscle
2) posterior – posterior border of the sternocleidomastoid muscle
3) superior – skull base
4) inferior – level of the hyoid bone (clinical landmark) or carotid
bifurcation (surgical landmark)
Level IIa* and IIb* are arbitrarily designated anatomically by splitting level II with the spinal accessory nerve.
Level III: Lymph node groups – middle jugular
Boundaries – 1) anterior – lateral border of the sternohyoid muscle
2) posterior – posterior border of the sternocleidomastoid muscle
3) superior – hyoid bone (clinical landmark) or carotid
bifurcation (surgical landmark)
4) inferior – cricothyroid notch (clinical landmark) or omohyoid
muscle (surgical landmark)
Level IV: Lymph node groups – lower jugular
Boundaries – 1) anterior – lateral border of the sternohyoid muscle
2) posterior – posterior border of the sternocleidomastoid muscle
3) superior – cricothyroid notch (clinical landmark) or omohyoid
muscle (surgical landmark)
4) inferior – clavicle
Level IVa* denotes the lymph nodes that lie along the internal jugular vein but immediately deep to the sternal head of the SCM. Level IVb* denotes the lymph nodes that lie deep to the clavicular head of the SCM
Level V: Lymph node groups – posterior triangle
Boundaries – 1) anterior – posterior border of the sternocleidomastoid muscle
2) posterior – anterior border of the trapezius muscle
3) inferior - clavicle
Level Va* denotes those lymphatic structures in the upper part of level V that follow the spinal accessory nerve. Level Vb* refers to those nodes that lie along the transverse cervical artery. Anatomically, the division between these to subzones is the inferior belly of the omohyoid muscle.
Level VI: Lymph node groups – [prelaryngeal (Delphian), pretracheal, paratracheal, and
precricoid (Delphian) lymph nodes] - also known as the anterior compartment
Boundaries – 1) lateral – carotid sheath
2) superior – hyoid bone
3) inferior – suprasternal notch
Level VII: Lymph node groups – Upper mediastinal
Boundaries – 1) lateral – carotid arteries
2) superior – suprasternal notch
3) inferior – aortic arch
Supraclavicular zone or fossa: relevant to nasopharyngeal carcinoma
Boundaries – 1) superior margin of the sternal end of the clavicle
2) superior margin of the lateral end of the clavicle
3) the point where the neck meets the shoulder
* Note: The subzones Ia, Ib, IIa, IIb, IVa, IVb, Va, and Vb were not part of the original description of the levels of the neck. They have been suggested by Suen and Goepfert (1987) to further subdivide areas of differing lymphatic drainage within certain levels. Depending on the site of the primary tumor, these subzones may have biological significance and can guide decision-making in determining which nodal levels should be addressed surgically. For example, level Ia is more likely to contain metastatic disease associated with primary lesions arising in the, lower lip, floor of mouth, and ventral tongue, whereas lesions arising from other oral cavity subsites are more likely to spread directly to level Ib, II, and III. Level II is divided into subzones anatomically by the spinal accessory nerve, however, subzones Level IIa and IIb have biologic implications as well. Primary lesions from the oropharynx and nasopharynx are more likely to involve level IIb. Therefore it is important to mobilize the spinal accessory nerve and remove the fibrofatty components containing lymph nodes from this compartment. Obviously level IIb should also be dissected when there are clinically positive lymph nodes in level IIa however, it may not be necessary to dissect level IIb when performing elective neck dissections for carcinomas arising from the oral cavity, larynx, and hypopharynx. Similarly Level IV may be subdivided into subzones. Clinically positive lymphadenopathy in Level IVa may signify a higher risk of spread to level VI whereas lymph nodes in Level IVb may be more likely to spread to level V. Level Va denotes those lymphatic structures coursing along with the spinal accessory nerve as it exits the posterior border of the SCM and enters the anterior border of the trapezius muscle. Tumors arising in the oropharynx, nasopharynx, and cutaneous structures of the posterior scalp and neck are more likely to involve these lymph nodes. Level Vb refers to those lymph nodes lying along the transverse cervical artery and are anatomically separated from Level Va by the inferior belly of the omohyoid muscle. These notes have a high risk of involvement in metastatic thyroid cancers.
The "N" or nodal classification for cervical metastasis is consistent for all mucosal sites except the nasopharynx. Thyroid and nasopharyngeal carcinomas have unique nodal classifications that are based upon tumor behavior and prognosis. The staging systems for cervical metastases have been established by the American Joint Committee on Cancer most recently updated in 1997. These systems are based on the best possible estimate of the extent of disease before first treatment. Clinical information including physical exam and imaging modalities are used to contribute to this estimate.
Regional Lymph Nodes (N)
oral cavity, oropharynx, hypopharynx, larynx, trachea, paranasal sinuses, major
salivary glands,
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Single ipsilateral lymph node 3-6 cm
N2a Single ipsilateral lymph node 3-6 cm
N2b Multiple ipsilateral nodes < 6 cm
N2c Bilateral lymph nodes < 6 cm
N3 Any node > 6 cm
NX nodes cannot be assessed
N0 no regional lymph node metastasis
N1 Unilateral metastasis in lymph nodes < 6 cm above the supraclavicular fossa
N2 Bilateral metastasis in lymph nodes < 6 cm above the supraclavicular fossa
N3 Metastasis in a lymph node(s)
N3a > 6 cm
N3b extension to the supraclavicular fossa
NX Regional lymph noses cannot be assessed
N0 No regional lymph node metastasis
N1 Regional lymph node metastasis
N1a Metastasis in ipsilateral cervical lymph node(s)
N1b Metastasis in bilateral, midline, or contralateral cervical or mediastinal lymph
In 1991, the Committee for Head and Neck Surgery and Oncology of the American Academy of Otolaryngology/Head and Neck Surgery developed a system for the classification of neck dissections. Other individual authors prior to and since this time have proposed other classification systems, however, the Academy's system remains the most widely accepted and has been endorsed by the American Society for Head and Neck Surgery. It is based on the following concepts:
1) Radical neck dissection is the standard basic procedure for cervical
lymphadenectomy against which all other modifications are compared.
2) Modifications of the radical neck dissection which include the preservation of any non-lymphatic structures are referred to as modified radical neck dissection (MRND)
3) Any neck dissection that preserves one or more groups or levels of lymph
nodes is referred to as a selective neck dissection.
4) An extended neck dissection refers to the removal of additional lymph node
groups or non-lymphatic structures relative to the radical neck dissection.
The following are the four major types and subtypes of neck dissections proposed by the Academy:
1) Radical neck dissection (RND)
2) Modified radical neck dissection (MRND)
3) Selective neck dissection (SND):
a. supra-omohyoid type
b. lateral type
c. posterolateral type
d. anterior compartment type
4) Extended radical neck dissection
In 1989 Medina suggested that the term "comprehensive neck dissection" be used whenever all the lymph nodes contained in levels I through V have been removed. The radical neck dissection and the modified radical neck dissection would, therefore, be included under this title. He then recommended three subtypes of modified radical neck dissection. This additional nomenclature has the disadvantage of adding further complexity to the classification system, however it may be more conducive to consider adding such refinements to the Academy's system now that most head and neck surgeons are familiar with its structure and concepts. Medina's classification is as follows:
Comprehensive neck dissection
Radical neck dissection
Modified radical neck
Type I (XI preserved)
Type II (XI, IJV preserved)
Type III (XI, IJV, and SCM
Selective neck dissection (a-d as above)
In 1994,
Spiro suggested changes to the Academy's classification of neck
dissections. He recommended that the
term "radical neck dissection" be used for any neck dissection in which four or
more lymph node levels are removed, and that the term "modified radical neck
dissection" be included under the heading of RND. Additionally they included two other types of
neck dissection: selective and limited. He believed that his system more accurately
reflected the time and effort involved and provided a "more equitable basis for
reimbursement". The following table describes Spiro's "three-tiered" classification:
Radical (4 or 5 node levels resected)
Conventional radical neck dissection
Modified radical neck dissection
Extended radical neck dissection
Modified and extended radical neck dissection
Selective (3 node levels resected)
Supraomohyoid neck dissection
Jugular dissection (Levels II-IV)
Any other 3 node levels resected
Limited (no more than 2 node levels resected)
Paratracheal node dissection
Mediastinal node dissection
Any other 1 or 2 node levels resected
The Academies system for classification of neck dissection as compared to others has the advantage of being simple, logical, based on historical terminology, and most importantly, represents a consensus of opinions by the two organizations at the time it was developed. Therefore, it has become the most widely accepted and utilized system throughout the world. It is not perfect, however. Not all neck dissections fit perfectly into the classification. Thus, there will be continued discussion and debate concerning the nomenclature used in these situations.
Radical neck
The radical neck dissection is the gold standard for oncologic treatment of lymph node metastasis in the neck. It involves removal of all lymphatics from levels I-V. In addition, removal of nonlymphatic structures including the spinal accessory nerve, the sternocleidomastoid muscle and the internal jugular vein is carried out. It does not include removal of the postauricular and suboccipital nodes, periparotid nodes except for a few nodes located in the tail of the parotid gland, the perifacial and buccinator nodes, the retropharyngeal nodes, and the paratracheal nodes.
Decision to perform a radical neck dissection is not always straight forward, and often is determined at the time of surgery. A RND is indicated in patients with extensive cervical lymph node metastasis and/or extension beyond the capsule with invasion into the spinal accessory nerve, IJV, and SCM. Many surgeons will elect to perform a RND if there is extensive disease surrounding the spinal accessory nerve without gross evidence of invasion. Others would elect to perform a MRND. The bottom line is the one should not risk inadequate oncologic resection for the sake of preserving these any of these nonlymphatic structures.
Modified Radical Neck Dissection
Modified radical neck dissection involves excision of the same lymph node bearing tissues from one side of the neck as is performed in a RND with the preservation of one or more nonlymphatic structure including the spinal accessory nerve, the IJV, or the SCM. As mentioned before, Medina subclassifies the MRND into Types I-III (see Medina's classifications above). MRND is analogous to the "functional neck dissection" described by Bocca, however they differ in that Bocca originally did not remove the submandibular gland.
MRND is indicated in patients with gross nodal metastasis to the neck that does not directly infiltrate or adhere to the non-lymphatic structures previously mentioned. Bilateral MRND is indicated when there is contralateral nodal involvement with the above mentioned specifications. In these cases it is important to plan ahead if sacrifice of both IJVs is anticipated because bilateral resection results in massive edema and cases of blindness (ischemic optic neuropathy), stroke, and death have been reported. Preservation of the IJV in MRND results in IJV patency rates of 86-99% excluding patients with compression of the IJV by tumor recurrence. If decision to preserve IJVs is decided on, care should be taken to avoid endothelial damage by atraumatic handling, by tying instead of cauterizing tributaries of the IJV, and by avoiding desiccation. If both veins are involved with tumor, the therapeutic options include staging the second neck dissection, or to proceed with bilateral IJV resection with, or without reconstruction. The IJV may reconstructed in several different ways. Interposition grafts with spiraled saphenous vein is the preferred method. In addition, a segment of the contralateral (resected) IJV, polytetrafluoroethylene (PTFE), or the external jugular vein may be used.
Modifications of the classic RND aim to reduce postsurgical neck pain and shoulder dysfunction encountered when the spinal accessory is resected without compromising adequate oncologic treatment. The earliest studies as mentioned previously by Bocca found no difference in those patients treated with MRND vs RND. Many subsequent studies have supported this finding. Anderson and colleagues (1994) found the actuarial 5-year survival and neck failure rates for RND were 63% and 12% respectively compared to 71% and 12% for MRND Type I. These results were not statistically different when controlled for pathologic N stage, presence of extracapsular spread, and pathologic presence of nodes along the spinal accessory nerve. Additionally, there was no difference in the pattern of neck failure.
Sacrifice of the SCM and IJV is less debilitating. SCM preservation, however, improves cosmetic appearance and protects the carotid artery if adjuvant radiotherapy is employed. The oncologic safety of preserving the SCM has been established by pathologic studies. In one study Calearo (1983) found no evidence of SCM invasion in a series of 98 RNDs for oral cancer, despite 73 having pathologic metastases. More recently, Jaehne (1996) looked at of 101 RNDs performed for N+ disease and found that only 12% of cases had SCM invasion. This higher incidence may reflect the trend toward more conservative surgery with RND reserved for cases where there is obvious invasion of nonlymphatic structures. Preserving the IJV becomes more significant in patients requiring bilateral neck dissections. MRND type II is rarely planned, as it is uncommon for metastatic disease to invade the SCM and not the IJV so when gross invasion of the SCM is not seen preservation of both the SCM and IJV should be considered. MRND Type III evolved from work by Suarez (1963) who observed in autopsy and surgical specimens of the larynx and hypopharynx that the lymph nodes were in fibrofatty tissue, and even when near blood vessels but did not share the same adventitia.
Selective Neck Dissection: Supraomohyoid Type (Level I-III)
The supraomohyoid neck dissection (SOHND) is the most commonly performed selective neck dissection for the treatment of the N0 neck. It involves the en bloc removal of cervical lymph node groups I-III. The posterior limit of this dissection is marked by the cutaneous branches of the cervical plexus and the posterior border of the SCM. The inferior limit is the superior belly of the omohyoid muscle where it crosses the IJV.
SOHND is indicated in patients with primary tumors arising from the oral cavity without clinical or radiologic evidence of cervical metastasis but who have a high probability of occult lymphatic disease. The oral cavity includes the area between the vermillion border of the lips and the junction of the of the hard and soft palate superiorly and the circumvallate papillae of the tongue inferiorly. Subsites in the oral cavity include the lips, buccal mucosa, upper and lower alveolar ridges, retromolar trigone, hard palate, and anterior two thirds of the tongue, and floor of mouth. Medina recommends SOHND in patients with staged T2-T4N0 or TXN1 when the palpable node is less than 3 cm, clearly mobile, and located in levels I or II.
Bilateral SOHND is indicated in patients who have carcinomas of the anterior tongue or oral tongue and floor of mouth that approach or cross the midline.
SOHND is indicated along with parotidectomy in patients with squamous cell carcinoma, Merkel cell carcinoma, or selected stage I melanomas (thickness between 1.5 and 3.99mm) in the cheek and zygomatic regions of the face.
The expectant management of patients with oral cavity tumors and N0 necks has been condemned because of the high incidence of occult nodal metastasis and poor salvage rates. One exception is carcinoma of the lower alveolar ridge, which has a low probability of neck metastasis. Byers does not advocate elective neck dissections in carcinomas of the buccal mucosa no matter what T stage. His series was comprised of ten patients all of whom had elective neck dissections from which no metastatic disease was found. In all patients who are candidates for any selective neck dissection, the decision to proceed with surgery versus radiation is based on the characteristics of the primary tumor, the skill and experience of the physicians involved, and the patient's wishes and general health.
The basis for which the SOHND was developed for treatment of the N0 neck in patients with oral cavity carcinomas was established by Lindberg's study in 1972 where he looked at the distribution of lymph node metastasis in head and neck squamous cell carcinomas. He showed that the subdigastric and midjugular nodes were the most likely affected lymphatics. In the absence of involvement of the first echelon node groups (submandibular, subdigastric, and midjugular) oral cavity carcinomas rarely spread to the lower jugular or posterior triangle lymph nodes. In 2001, Hoffman reviewed 5 of the largest series of oral cavity and calculated the mean percent occurrence of oral cavity tumors in all levels of the neck. Many of these studies included N+ necks. The results are a follows: Level I – 30.1%, Level II – 35.7%, Level III – 22.8%, Level IV – 9.1%, and Level V – 2.2%. When factoring in only No necks, the occurrence of occult nodal metastases in both Level IV and Level V was less than 3%. This finding supports the use of the SOHND in treatment of patients with N0 necks with oral cavity carcinoma.
Perineural spread to the cervical plexus is a potential source of regional recurrence. The cervical plexus is sacrificed in a radical and in modified radical neck dissections but preserved, at least in part, in selective neck dissections. In a study of 30 RND specimens, 25 were found to have extracapsular spread, but only one had histologic invasion of the cervical plexus; further supporting the oncologic safety of the selective neck dissection
Selective Neck Dissection: Lateral Type (Levels II-IV)
The lateral type neck dissection refers to the en bloc removal of the jugular lymph nodes including Levels II-IV.
The primary indications for the lateral type neck dissection include removal of nodal disease associated with carcinomas arising in the oropharynx, hypopharynx, and larynx.
The boundaries of the oropharynx are: anteriorly at the junction of the hard and soft palate and circumvallate papillae of the tongue base, superiorly at an imaginary line draw from the hard palate to the posterior oropharyngeal wall, and inferiorly at the pharyngoepiglottic folds. Structures contained in the oropharynx are the tonsils, tonsillar fossa, tonsillar pillars, tongue base and a portion of the posterior pharyngeal wall.
The hypopharynx extends from the hyoid bone superiorly to the cricoid cartilage
inferiorly and includes three subsites: the pyriform sinus, the postcricoid region, and the posterior hypopharyngeal wall.
The supraglottic larynx is bounded superiorly by the valleculae and extends inferiorly to the apex of the ventricle. It includes the epiglottis, the aryepiglottic folds, arytenoids, false vocal cords, and the superior aspect of the ventricle.
The boundaries of the larynx include the apex of the ventricle superiorly to a horizontal plane passing 1 cm below this point and includes the true vocal cords and the anterior and posterior commissures.
Oropharyngeal carcinoma has a high likelihood of metastasizing to the jugular lymph nodes in levels II-IV regardless of the size of the tumor. Overall, the risk of metastasis to these areas 30%-35%. Hoffman's review revealed that Level I was involved in 10.3 % and Level V in 7% of patients with oropharyngeal carcinoma. Again, further substantiating the low risk of tumor metastasis to these areas was supported by the fact that some of the studies reviewed included N+ necks. When only N0 necks were considered, these percentages dropped to less than 5%.
Because these tumors are in difficult locations to access surgically, often radiation will be chosen for the primary treatment modality. In these cases, it is reasonable to treat the neck or both necks if indicated with radiation.
Hypopharyngeal carcinomas are aggressive tumors that have rich lymphatics that tend to drain bilaterally. There is occult metastasis involved in 30% to 35% of patients most commonly to the subdigastric, upper and middle jugular lymph nodes. Retropharyngeal and paratracheal nodes are also at risk for harboring metastases. Often the primary tumor has extensive submucosal spread. Patients with bulky or extensive primary tumors (T3 or T4) will require combined radiation and surgical treatment. These patients usually undergo surgical treatment of the primary with bilateral neck dissection and adjuvant radiotherapy. Unilateral neck dissection with radiation to the other neck is also a consideration. T1 and T2 lesions may either be treated primarily with wide local excision or radiotherapy with good control rates. In 1994, Johnson et al. reviewed 169 patients with carcinoma of the hypopharynx. They separated these patients by location within the hypopharynx: medial pyriform (MP) or lateral pyriform (LP). Patients with MP carcinomas and N0 necks treated with ipsilateral were found to have 14% failure rate in the contralateral neck compared to 5% in patients with LP carcinomas. They, therefore, advocate bilateral neck dissection or radiotherapy in patients with MP tumors and unilateral treatment of the neck in patients with LP tumors.
Supraglottic larynx
Of all
subsites in the larynx, the supraglottis has the highest incidence of nodal
metastasis. Approximately 30% of
patients will have occult metastases most commonly to levels II-IV with greater
than 20% involvement of the contralateral side.
Shah and coworkers (1990) found that only 6% and 1% of patients who had
a radical neck dissection for clinically N0 disease had metastatic cancer in
levels I and V respectively. Based on
these finds bilateral selective II-IV neck dissections are advocated in
patients with supraglottic carcinomas with N0 necks. Again, radiation therapy is also an option in
these patients and decision making depends on multiple factors.
Glottic larynx
Glottic carcinomas metastasis late because of the sparse lymphatics and the anatomic barriers to lymphatic spread such as the conus elasticus. T1 and T2 carcinomas of the glottic larynx have less than 5% and 2% to 7% metastatic rate respectively. Expectant management of the neck in these patients is therefore accepted.
In two separate studies done by Byers (1988) and Candela (1990) found that recurrent T2 lesions have a much higher rate of metastasis (20%-22%). Therefore, ipsilateral neck dissection of levels II-IV is advocated in these patients with N0 necks. Patients with T3 and T4 have a 10% to 20% and up to 40% rate of occult nodal metastasis respectively. Because of this data and the fact that salvage rates in these patients is so dismal (70% die of disease) ipsilateral neck dissection of levels II-VI is advocated.
Selective Neck Dissection: Posterolateral Type (Levels II-IV, suboccipital and postauricular)
The posterolateral type neck dissection involves the en bloc excision of lymph bearing tissues in Levels II-IV and additional node groups including the suboccipital and postauricular nodes
This type of neck dissection is primarily used to treat the neck in patients with cutaneous malignancies (primarily squamous cell carcinoma, melanoma, and other skin tumors with metastatic potential, such as the Merkel cell carcinomas) and soft tissue sarcomas.
Selective Neck Dissection: Anterior Compartment Type (Level VI)
The anterior compartment neck dissection involves the en bloc removal of lymph structures in Level VI. The lymph node groups excised are the perithyroidal nodes, pretracheal, precricoid (Delphian), and paratracheal nodes located along each recurrent laryngeal nerve. The superior limit of the dissection is the hyoid bone and the inferior extent is the suprasternal notch. Laterally the dissection is carried out to the carotid sheath.
The anterior neck dissection is performed in the following situations: (1) selected cases of differentiated thyroid carcinoma, (2) parathyroid carcinoma (3) subglottic carcinoma (4) glottic carcinomas with subglottic extension, (5) cervical esophagus. Robbins (1998) also recommends this neck dissection in some patients with hypopharyngeal carcinoma as paratracheal nodes are at high risk for occult disease in these tumors.
Extended Neck Dissection
Extended neck dissection refers to any of the above listed dissections involving the removal of additional lymphatic groups or nonlymphatic structures (vascular, neural, or muscular) beyond what is normally included in that procedure.
Extended neck dissections are usually performed when MRND or RND is planned for N+ necks. The decision to extend the neck dissection may either be made preoperatively based on findings on CT or MR or intraoperatively based on findings of tumor invasion of surrounding structures. The most significant example is when cervical disease involves the carotid artery. Some authors feel that resection of the carotid artery is futile because of the poor prognosis of these patients and the significant risk incurred by undergoing this procedure. Others advocate resection with or without reconstruction determined by preoperative tolerance to carotid artery balloon occlusion.
Other examples where extended neck dissections are indicated include performing level VI neck dissection for carcinoma involving the subglottis and removal of retropharyngeal lymph nodes in one or both sides when the primary tumor originates in the pharyngeal walls.
Treatment of the neck in patients with head and neck malignancies is can be challenging and is certainly fraught with controversy. Over the past century, advances in surgical technique, diagnostic equipment, and radiotherapy have helped improve the treatment of these tumors, however, the finding of metastatic disease to the neck, particularly in squamous carcinomas of the upper aerodigestive tract, continues to portend a dismal prognosis.
The current classification of neck dissections has met worldwide acceptance, however, it is not perfect for every situation. As the field progresses, the existing classification will likely change to better unify terminology used by physicians who treat head and neck cancer.
Debate and
controversy continue to exist in the following areas:
1) Treatment of level IV in patients with N0 necks and carcinoma of the oral tongue
2) Supraomohyoid neck dissection: diagnostic or therapeutic?
3) Management of advanced cervical metastases (N2 and N3) after organ preservation
4) Sentinel node localization in head and neck squamous carcinoma
5) The role of elective and therapeutic neck dissections in thyroid cancer
6) Management of the necks in patients with superficial extension of glottic tumors to
the supraglottis
7) Management of carotid artery with involvement in cervical metastases
Finding solutions and consensus in these areas will be the challenge of the years to come.
Anderson, PE. The role of comprehensive neck dissection with preservation of the spinal accessory nerve in the clinically positive neck, Amer J Surg, 1994; 168:499-502
Bailey, Byron J.: Head and Neck Surgery-Otolaryngology, 3rd Ed. Lippincott-Raven, Philadelphia-New York, 2001, pgs 1345-1366
Bocca, E. and Pignataro, O.: A conservation technique in radical neck dissection. Ann Otol Rhinol Laryngol, 1967; 76:975.
Bocca, E. et. al.: Functional neck dissection, Arch Otolaryngol, 1980; 106:524-527.
Byers, RM, Newman, R, Russell, N, et al.: Results of treatment for squamous carcinoma of the lower gum. Cancer, 1981;47:2236-2238
Byers, RM, Wolf, PF, Ballantyne, AJ: Rationale for elective modified neck dissection. Head Neck, 1988; 10:160-167
Candela, FC, Shah, J, Jacques, DP, et al.: Patterns of cervical node metastases from squamous carcinoma of the larynx. Arch Otolaryngol Head Neck Surg, 1990;
Cotter, CS, Stringer, SP, Landau, S, et al.: Patency of the internal jugular vein following modified radical neck dissection. Laryngoscope, 1994; 104:841
Crile, George: Excision of cancer of the head and neck, J Am Med Assoc, December, 1906; 47:1780-1786
Hoffman, HT: Surgical treatment of cervical node metastases from squamous carcinoma of the upper aerodigestive tract: evaluation of the evidence for modifications of neck dissection. Head Neck, 2001; 23:907-915
Jaehne, M, Ussmuller, J, Kehrl, W. Significance of sternocleidomastoid muscle resection in radical neck dissection. HNO, 1996; 44(12):661-665
Janfaza, P. et al.: Surgical Anatomy of the Head and Neck. Lippincott Williams and Wilkins, Philadelphia, Pennsylvania, 2001; 507-627
Johnson, JT, Myers, EN: Cervical lymph node disease in laryngeal cancer. In Silver CE (ed): Laryngeal Cancer. New York, Thieme Medical, 1991, pp 22-26
Kraus DH, Rosenberg DB, Davidson BJ, et al.: Supraspinal accessory lymph node metastases in supraomohyoid neck dissection. Am J Surg, 1996; 172:646-649
Lindberg, R.: Distribution of cervical lymph node metastases from squamous cell carcinoma of the upper respiratory and digestive tracts, Cancer, 1972; 29:1446-1449
Martin H, DelValle B, Ehrlich H, Cahan WB. Neck dissection. Cancer, 1951; 4:441-499
Medina, JE: A rationale classification of neck dissections. Otolaryngol Head Neck Surg, 1989; 100:169-176
Medina, JE, and Weisman, RA: Management of the neck in head and neck cancer, Part I. The Otolaryngologic Clinics of North America, 1998; 31(4)
Medina, JE, and Weisman, RA: Management of the neck in head and neck cancer, Part II. The Otolaryngologic Clinics of North America, 1998; 31(5)
Meyers, Eugene N.: Operative Otolaryngology-Head and Neck Surgery. W. B. Saunders company, Philadelphia, Pennsylvania, 1997.
Million, RR: Elective
neck irradiation of Tx No squamous carcinoma of the oral tongue and floor of
mouth. Cancer, 1974 34:149-155
Pietrantoni L: Il problema chirurgico delle metastasi linfoghiandolari del cancro della laringe. Arch Ital Otol, suppl 14, 1953
Robbins, TK et al.: Standardizing neck dissection terminology, Arch otolaryngol head neck surg, June 1991; 117:601-605
Shah, JP: Patterns of lymph node metastases from squamous carcinomas of the upper aerodigestive tract. Am J Surg, 1990; 160(4) 405-409
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Suen JY, Goepfert H: Standardization of neck dissection nomenclature [editorial]. Head Neck Surg 10:75-77, 1987
Talmi, YP, Hoffman, HT, Horowitz, Z, et al. Patterns of metastases to the upper jugular lymph nodes (the "submuscular recess"). Head Neck, 1998;20(8):682-686


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Reading Buddies
Be a Reading Buddy after school at the Glenwood Springs Branch Library. After starting off with a group game and snack, younger readers are partnered with older reading buddies to practice and develop a love for reading. Before Reading Buddies is over we also offer those kids who need to do homework or have independent reading time a chance to choose their activity. Reading Buddies is open to kids from kindergarten through eighth grade and meets at the library at 413 9th Street from 4:00 to 5:00 pm every Tuesday during the school year.
For more information, contact the Glenwood Springs Branch Library at (970) 945-5958.

subset: commoncrawl


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DrumMania (alternately drummania, abbreviated DM) is a music video game series produced by Konami Digital Entertainment, Inc., where colored notes travel down the screen which correspond with color coded parts of an electronic drum set. The player must hit the drum parts when the notes reach the bottom of the screen in order to fill in missing drum parts from a song.
Earlier versions of DrumMania which includes before the release of DrumMania 10th Mix, have been released in Asian countries, under the title Percussion Freaks.
Since DrumMania V, DrumMania and GuitarFreaks had been united with a single version number as part of the 5th Anniversary of the video game. As of writing, DrumMania V5 is the latest version of the DrumMania series, and it links to GuitarFreaks V5. They are essentially the 15th and 16th versions of each.
Konami has not mass produced an American version of DrumMania, primarily since John Devecka holds the US patent for "drum simulation games", which Activision had purchased and utlized in Guitar Hero series. Even with this possible obstacle in mind, Konami has tested English builds of DrumMania and Guitar Freaks V4 at the ATEI exhibition in London and at a Brunswick Zone bowling alley in Naperville, Illinois - though official releases have not been announced. Nonetheless, imported versions of DrumMania can be found in various locations across the United States and Canada.
The pads are actually a modified version of the DTXPRESS electronic drum kit made by Yamaha Corporation which is available in almost any musical chain store.
To the right of these pads, there are three buttons, Left, Start and Right, which are used to select and decide in the selection screens. In those cases, the Left button is assigned to the snare drum pad, Right to the low tom, and Start to the cymbal.
To play the correct note, the player must hit one or two of these pads and/or step the pedal when the note bars reach the yellow line. The note scroll in DrumMania is in essence a drum tablature timed with the music and placed vertically.
The player's accuracy is judged for each note played, and while the individual note judgments have changed throughout the series, the current system uses Perfect, Great, Good, Poor, and Miss to evaluate performance of each note. Ratings of Poor or Miss will deplete the player's "Excite Gauge", while accurate play will replenish it.
If the Excite Gauge is emptied completely, the game ends. Players will be able to play anywhere from three to five songs depending on the game's configuration, with the potential to earn one or two additional stages in certain versions of the game if performance is good enough.
At the completion of a song, players are given a letter rank for their performance which can range anywhere from E to A, as well as S and SS depending on how well the song was played, and how the particular release of the game being played computes ranks.
However, when linked with Keyboardmania, only about a dozen songs are available to play. Keyboardmania 3rd Mix can be linked with GuitarFreaks 5thMIX and DrumMania 4thMIX, or GuitarFreaks 6thMIX and DrumMania 5thMIX.
Since 9th Mix, the series has taken advantage of Konami's e-Amusement system, which adds several online capabilities to the game:
Players can select NORMAL, PERFECT or COMBO modes upon selection of the song to determine the final calculation. Upon winning or losing, they will be entitled to promote or demote to another higher BATTLE CLASS rated from D3 to SS, where players are sorted according how well they have successfully defeated opponents.
However, without the use of the e-AMUSEMENT Pass, if there are additional Drummania machines in the arcade, an additional Battle Mode (Local) option is created, just like in a LAN. They have the same functionaility as the Battle Mode (Worldwide); otherwise do not have Battle Classes to sort the players.
Other than Battle Mode (Local), alternatively players can select the Battle Mode (CPU) which is also available only Drummania machines without e-AMUSEMENT access. This mode allows players to complete with the CPU, rather than a player.
However, an online registration must be submitted via the BEMANI TOP RANKER website and the player must play the complusory songs to determine the players who will be representing for their country.
As of Drummania V4, Skill Points are dependent on the first 14 songs released for the particular mix, next 36 songs from previous mixes and last 3 long songs from any mix played throughout the song list.
The previous mixes uses a different calculation of Skill Points since NON-STOP Mode is abolished in Drummania V4. The old skill point calculation is dependent on the first 13 songs released for the particular mix, next 35 songs from previous mixes, 2 long songs from any mix and the last 3 non-stop courses played throughout the song list.
Skill Points are awarded upon successful completion of a song, and depending on how well the Skill Percentage earned for the particular song, the player earns the amount of Skill Points reflected at the end of the game.
As of DrumMania V5, the arcade versions of DrumMania have contained over 700 songs in total. Most songs are either crossovers from other Bemani games, J-pop and J-rock. Some mixes also contain covers of popular North American songs.
A handful of DrumMania simulators have been created for use on PCs, the most popular of which is called DTXMania, which also supports GuitarFreaks. It can be controlled using the computer keyboard, any USB device that can act as a joystick, or any MIDI instrument such as a MIDI keyboard or professional quality electronic drum kit. This is also compatible with the Rock Band Series Drum Sets


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A single copy of this article may be reprinted for personal, noncommercial use only.
Lung transplant
By Mayo Clinic staffOriginal Article: http://www.mayoclinic.com/health/lung-transplant/MY00106
Lung transplant |
A lung transplant is a surgical procedure to replace a diseased or failing lung with a healthy lung, usually from a deceased donor. Depending on your medical condition, a lung transplant may involve replacing one of your lungs or both of them. In some situations, the lungs may be transplanted along with a donor heart.
Living-donor lung transplants are rare. This procedure can replace a child's diseased lung with a section (lobe) of a lung taken from a healthy adult — usually a parent. Two living donors are needed if the procedure is used for an adult.
Why it's done
Unhealthy or damaged lungs can make it difficult for your body to get the oxygen it needs to survive. A variety of diseases and conditions can damage your lungs and hinder their ability to function effectively, including:
- Chronic obstructive pulmonary disease (COPD), including emphysema
- Scarring of the lungs (pulmonary fibrosis)
- Cystic fibrosis
- Sarcoidosis with advanced fibrosis
- Pulmonary hypertension
Lung damage can often be treated with medication or with special breathing devices. When these measures no longer help or your reduced lung function becomes life-threatening, your doctor might suggest a lung transplant.
Complications associated with a lung transplant can sometimes be fatal. The two major risks are rejection and infection.
Risk of rejection
Your immune system defends your body against foreign substances. Even with the best possible match between you and the donor, your immune system will try to attack and reject your new lung or lungs. Your drug regimen after transplant will include medications to suppress your immune system in an effort to prevent organ rejection. You'll likely take these anti-rejection drugs for the rest of your life.
Side effects of anti-rejection drugs
Anti-rejection drugs may cause noticeable side effects, including:
- Weight gain
- A rounder face
- Acne
- Facial hair
- Stomach problems
Some anti-rejection medications can also increase your risk of developing new or aggravating existing conditions, such as:
- Diabetes
- Kidney damage
- Osteoporosis
- Cancer
Risk of infection
The anti-rejection drugs suppress your immune system, making your body more vulnerable to infections, particularly in your lungs. To help prevent infections, you should:
- Wash your hands often
- Take care of your teeth and gums
- Protect your skin from scratches and sores
- Avoid crowds and people who are ill
- Receive appropriate immunizations
How you prepare
The number of people needing lung transplants far exceeds the number of donated lungs available. When a donor organ becomes available, the donor-recipient matching system administered by the United Network for Organ Sharing (UNOS) finds an appropriate match based on specific criteria, including:
- Blood type
- Size of organ compared with chest cavity
- Geographic distance between donor organ and transplant recipient
- Severity of the recipient's lung disease
- Recipient's overall health
- Likelihood that the transplant will be successful
Your health information must be updated every six months.
While you wait
It may take months or even years before a suitable donor becomes available, but you must be prepared to act quickly when one does. Make sure the transplant team knows how to reach you at all times. Keep your packed hospital bag handy — including an extra 24-hour supply of your medications — and arrange transportation to the transplant center in advance. You may be expected to arrive at the hospital within just a few hours.
At the hospital
Once you arrive at the hospital, you will undergo tests to make sure the lung is a good match and that you are healthy enough to have the surgery. The transplant will be canceled if it doesn't appear that the surgery will be a success.
What you can expect
Lung transplant |
During your lung transplant
The procedure will be done under general anesthesia, so you'll be asleep and you won't feel any pain. Doctors will insert a tube through your mouth and into your windpipe to help you breathe. You will also have a tube in your nose down to your stomach to drain your stomach contents. A catheter will keep your bladder empty.
Your surgeon will make a cut in your chest to remove your diseased lung. The main airway to that lung and the blood vessels between that lung and your heart will then be connected to the donor lung. For some lung transplants, you may be connected to a heart-lung machine, which circulates your blood during the operation.
A single-lung transplant takes about four to eight hours to complete, while a double-lung transplant usually takes six to 12 hours.
After your lung transplant
Immediately after the surgery, you'll spend several days in the hospital's intensive care unit. A mechanical ventilator will help you breathe for a few days and tubes in your chest will drain fluids from around your lungs and heart. A tube in a vein will deliver strong medications to control pain and to prevent rejection of your new lung. As your condition improves, you'll no longer need the mechanical ventilator and you'll be moved out of the intensive care unit. Recovery often involves a one- to three-week hospital stay.
After you're discharged from the hospital, you'll require about three months of frequent monitoring by the lung transplant team to prevent, detect and treat complications and to assess your lung function. During this time, you'll need to stay close to the transplant center. Your follow-up visits may involve laboratory tests, chest X-rays, an electrocardiogram (ECG) and checkups with a specialist.
Living a healthy lifestyle is key to sustaining your new lung. Smoking isn't allowed, and the use of alcohol is strictly limited. Following a nutritious diet also can help you stay healthy. Exercise is an extremely important part of rehabilitation after your lung transplant. Your health care team will work with you to design an exercise program that's right for you.
A lung transplant can substantially improve your quality of life. The first year after the transplant — when surgical complications, rejection and infection pose the greatest threats — is the most critical period. Although some people have lived 10 years or more after a lung transplant, only about half the people who undergo the procedure are still alive after five years.
- What is a lung transplant? National Heart, Lung, and Blood Institute. http://www.nhlbi.nih.gov/health/dci/Diseases/lungtxp/lungtxp_all.html. Accessed July 20, 2010.
- Kotloff RM. Lung transplantation: Available surgical techniques. In: Mason RJ, et al. Murray and Nadel's Textbook of Respiratory Medicine. 5th ed. Philadelphia, Pa.: Saunders Elsevier; 2010. http://www.mdconsult.com/book/player/book.do?method=display&type=bookPage&decorator=header&eid=4-u1.0-B978-1-4160-4710-0..00095-X--s0035&displayedEid=4-u1.0-B978-1-4160-4710-0..00095-X--s0050&uniq=210775695&isbn=978-1-4160-4710-0&sid=1028228499#lpState=opened&lpTab=contentsTab&content=4-u1.0-B978-1-4160-4710-0..00095-X--s0035%3Bfrom%3Dtoc%3Btype%3DbookPage%3Bisbn%3D978-1-4160-4710-0. Accessed July 21, 2010.
- Reilly JJ, et al. Surgical approach to lung disease: Lung transplantation. In: Goldman L, et al. Cecil Medicine. 23rd ed. Philadelphia, Pa.: Saunders Elsevier; 2007. http://www.mdconsult.com/das/book/body/210628108-3/1027851891/1492/405.html#4-u1.0-B978-1-4160-2805-5..50107-5--cesec1_4298. Accessed July 20, 2010.
- A guide to lung transplantation. American College of Chest Physicians. http://www.chestnet.org/downloads/patients/guides/LungTransplantation.pdf. Accessed July 20, 2010.
- Hachem RR. Lung transplantation: An overview. http://www.uptodate.com/home/index.html. Accessed July 21, 2010.
- Questions and answers for transplant candidates about lung allocation policy. United Network for Organ Sharing. http://www.unos.org/SharedContentDocuments/Lung_Patient(1).pdf. Accessed July 21, 2010.
- Barbara Woodward Lips Patient Education Center. About your lung transplant. Rochester, Minn.; Mayo Foundation for Medical Education and Research: 2006.
- Kotloff RM. Lung transplantation: Outcomes. In: Mason RJ, et al. Murray and Nadel's Textbook of Respiratory Medicine. 5th ed. Philadelphia, Pa.: Saunders Elsevier; 2010. http://www.mdconsult.com/book/player/book.do?method=display&type=bookPage&decorator=header&eid=4-u1.0-B978-1-4160-4710-0..00095-X--s0035&displayedEid=4-u1.0-B978-1-4160-4710-0..00095-X--s0050&uniq=210979417&isbn=978-1-4160-4710-0&sid=1028763288#lpState=closed&lpTab=contentsTab&content=4-u1.0-B978-1-4160-4710-0..00095-X--s0065%3Bfrom%3Dtoc%3Btype%3DbookPage%3Bisbn%3D978-1-4160-4710-0. Accessed July 22, 2010.


text: Part of me is sad that the Yanks didn't make it to the postseason this season. However, part of me is happy, given the fact that Torre took the Dodgers into the playoffs. It will likely go down as one of the dumbest things the Yankees ever did when they shoved Torre out the door. If they had any sense, they'd use all that extra cash they'll have laying around this offseason and throw however much $$$ it takes at Torre to get him to come back. Torre earned the right to manage in the final season at Yankee Stadium. Letting him go was a bad business decision and an even worse baseball move. I have been die-hard supporter of the Yankees for quite some time now, but must admit that I mostly kept up with them half-heartedly this season. I did make the trip from SC to see a game in Yankee Stadium and saw them lose to KC. They really just displayed no fire or grit this season. Much of that has been lacking since the loss of Paul O'Neill, but the loss of Torre pretty much wiped it out. Jeter is a gamer for sure, but he doesn't have a fiery personality like O'Neill did. The Yankees now just don't inspire me at all. They plod out onto the field and don't really look like they really care that much about what happens. All of these negative comments exclude Jeter, Rivera, Posada and Pettite. 6 years ago I'd throw something across the room when the Yankees lost a game. Now I just kind of shrug my shoulders and go on doing something else online.


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'Bonnie & Clyde' Mini Delivers 9.8 Million Viewers for A&E Networks
Sunday's premiere also scored 4.2 million viewers in the key 25-54 demographic.
Sunday's premiere also scored 4.2 million viewers in the key 25-54 demographic.
'Tis the season for holiday fun, family and…movies. So we asked Duck Dynasty's Jep and Jessica Robertson to pick their favorite holiday movies currently available with XFINITY On Demand. Their… More
"Sesame Street's" latest pop parody is "Lord of the Crumbs," a spoof of Lord of the Rings starring Cookie Monster as the Gollum-esque Gobble. (Extra points for the grossly stringy hair.)
Benedict Cumberbatch's Sherlock Holmes is alive, and he needs to get reacquainted with London in the Season 3 launch trailer for BBC One's "Sherlock."
Ruben Studdard says there was no "conspiracy" behind his return to "The Biggest Loser" last month after being eliminated a week earlier.
As a member of the Executive Voting Committee, "Survivor" Co-Executive Producer Matt Van Wagenen (along with Challenge Producer John Kirhoffer and other "Survivor" luminaries) has an awesome responsibility.
The Sportsman Channel said Monday it has hired Sarah Palin to be host of a weekly outdoors-oriented program that will celebrate the "red, wild and blue" lifestyle.
MTV appears to have cancelled "Teen Mom 3," although the end of the spinoff does not mean the entire "Teen Mom" series is coming to an end.
One of the highlights of Saturday's uneven episode of "Saturday Night Liv" was the return of the beloved "Bill Brasky" sketch. However, not everyone was so happy to see it.
Jon Bernthal played one of the walking wounded as Shane on "The Walking Dead." And, he is still playing a guy who knows how to take his lumps as Detective… More
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A blog about movie news, movie stars, movie premieres and the business of the big screen.
About music, artists and the news that envelops the industry.


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Drawing cartoons
Zalivka Mobile
A perfect storytelling tool and a cartoon studio in your pocket! If you want to become a filmmaker but have no time for professional tools, try this editor that is simple enough to be used by kids.
Drawing Cartoons is an animation editor that allows you to create your own movies. You don't need to draw every frame to get smooth motions. Instead of this, you draw keyframes only and intermediate ...
This Android app does not currently have any videos
We couldn't find videos for this Android app. Can you suggest one (it must be hosted on YouTube)?
Updated: December 11, 2013
Publisher: Zalivka Mobile
Version Varies with device
Drawing Cartoons by xoomxoom
A great primer to animation. Learn how to draw and rotate the characters in the 3D space. The tutorials are also helpful. Recommend!


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3pearlskids Fuchsia Kindergarten Rocks Rhinestone Top Little Girl 4-6
Bling it on in this cute little girl fuchsia rhinestone top by 3pearlkids!This item will ship to you from our warehouse in approximately 5 business days. Please allow for this additional processing time prior to shipment.
Bling it on in this cute little girl fuchsia rhinestone top by 3pearlkids ! Short sleeve top features multi color 'Kindergarten' rhinestone bling motif with 'ROCKS' in clear rhinestone. What a fashion statement for your little girl!
Fabric and Care: 100% Cotton. Machine wash cold water, no bleach, tumble dry low.
Brand: 3pearlskids
Price: $17.99
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Description: A collection of three massive, cinematic trailers. All very different, but each can supply your project with that "larger than life" sound. Each is made up of hybrid elements(orchestral and digital elements) that are very popular in today's modern trailers. Download the preview and see if it makes your trailer/promo shine. If you need help editing or customization, just buy the track twice and write me via my profile page. All variations are included.
1.Trailer: 2:07
2.Glitchy Disease Rising Trailer: 2:16
3.Cinematic: 2:58
Thank you so much for taking the time to stop by.
I live in Salt Lake City UT USA and have been composing/producing music for about 10+ years now. Its my life's passion and I'm very grateful to be able to make money with it.
A little shameless vanity: My music has been played on ABC, MTV, TLC, HBO, TNT, OWN and other networks, as well as used by hundreds of corporations, commercials and trailers.
VideoHive Artists! Your free to use any of my tracks, just let me know and I'll paste a link to the video you use it in.
Again thank you so much for stopping by, your the reason I get to do what I love!...even if you don't use anything today, hopefully you'll be back


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Making a Molehill out of a Mountain Featured
I am a part of a small writer's group here in my area and each week we pick a word and write whatever we want to pertaining in some way to that word. One of our words was "Mountain." Here is what I wrote…
I have a bumper sticker on my van that reads "Don't lie to kids." Many people ask me why I have it there, what does it mean? It means what it says. Tell the truth.
Recently I was at the Y in an aerobic class and noticed the words they have tacked up on the wall for the young ones who come in for gymnastics. These words are repeated all along one wall: respect, honesty, generosity, etc. Trying to teach children how important all these things are so they'll grow up with the right ideals and be good adults. I guess they're doing the "if-they-SEE-the-words-enough- it-will-make-a-difference" thing.


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VisitScotland uses cookies to enhance your experience on our website. By using our website you consent to our use of cookies. Please read our new privacy and cookies statement for more information.
Overview of Things to do
Overview of About Scotland
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Overview of Travel
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Blair Athol Distillery is one of the oldest working distilleries in Scotland. After enjoying a leisurely conducted tour, you can mull over the distinctive character of the finished article as you sip your dram of Blair Athol 12 Year Old.
For public transport information to visit here from within Scotland, enter your postcode and visit date below.
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Healthcare Professionals
Choose Mercy
Are you uninsured and living in cook county? Mercy is pleased to share we accept County Care--a new Medicaid option for adults living in cook county. LEARN MORE > |
Need Health Insurance? The Affordable Care Act (ACA) requires everyone legally living in the U.S. to have health insurance beginning January 1, 2014. And it also gives millions of individuals with too little OR no insurance, access to health plans at different cost levels. LEARN MORE > |
3-D Laparascopic Surgery
Mercy Hospital became the first hospital in the state of Illinois to receive and begin using the revolutionary, state-of-the-art 3D surgical technology when general surgeon Rami Lutfi, MD performed the first minimally invasive cholecystectomy (gallbladder removal surgery) using the Olympus 3D Laparoscopic Surgical Video System. READ MORE > |


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8 hrs ago | New York Business.com
Biz group sings goodbye to Bloomberg
The day after Mr. Bloomberg's eighth and final speech as mayor to the Association for a Better New York, another private-sector booster of his, the Partnership for New York City, hosted the businessman mayor's speech at its annual breakfast meeting.
What Do You Know About Conspiracy Theories?
Should we change our lifestyles to help reduce global warming?
James Ferrari, Montrose Derailment Victim, Mounred
Funeral services were held at Church of the Divine Love on Sunset Road in Montrose for Ferrari, 59, who was one of four people killed when a Metro-North train derailed in The Bronx.
'Parranda' and 3 Kings fiesta comes to Lehman Center
The Bronx will be the site of a tropical-style, holiday music fiesta. "Parranda Navide a," a Christmas celebration featuring jibaro music from the mountains of Puerto Rico, will light up the stage at the Lehman Center for the Performing Arts.
Bronx Wanderers holiday show Friday in Norwich
One part oldies, two parts rock 'n' roll, The Bronx Wanderers are a father and two sons united by their passion for great music regardless of the decade: former gold record producer Yo' Vinny and sons Vinny "the Kid" and Nicky "Stix."
'Chain' gang comes to Brooklyn, Bronx
An Art-deco Starbucks in the Parkchester neighborhood of the Bronx. According to a new report, no new Starbucks opened in the Bronx in 2012, though four Dunkin Donuts did.
Metro-North Resumes Service on Hudson Line for Wednesday Commute
Metro-North service on the Hudson Line was set to be nearly back to normal for the Wednesday morning commute three days after the deadly post-Thanksgiving accident , according to the MTA's website .
My selfie with Brooklyn Bridge suicide dude
America's selfie obsession reached a new low on Tuesday when a woman snapped a cellphone self-portrait that also captured a suicidal man on the Brooklyn Bridge.
The Moreland game: Cuomoa s commission comes up short
So New York has a problem with politicians skimming tax dollars, and other politicians have the solution: Just give us the dough up front, please, and call it reform.
Metro-North engineer 'caught himself' nodding before crash, union official says
In Nassau Cnty accident. right lane blocked on The Southern St Pkwy EB between Elmont Rd and Central Ave/Linden Blvd/X13.
The Bronx's BOOM!Health Films the Zombie Apocalypse to Fight...
Stigma toward people with HIV, hepatitis C and drug addiction means they end up being treated like zombies, shunned away from support and care.
Reports: Train Engineer 'Zoned Out' Before 82 mph Crash
The driver of the New York commuter train that derailed killing four people and injuring 63 dozed off minutes before the horror crash, investigators believe.
Joel announces Madison Square Garden residency
Billy Joel smiles during news conference at Madison Square Garden, Tuesday, Dec. 3, 2013 in New York.
The holidays are over - for now - and the art world has shifted back into gear. Sure, everyone might be talking about the Miami art fairs, but there's plenty going on elsewhere.
In time the Broncks' farm will become a favorite getaway for city dwellers and an outing to the area will become known as "going to the Broncks" - leading The Bronx to become the name of the whole county.
And this is his first-ever American retrospective. Metropolitan Museum of Art , through March 9. TV 2. Revisit Family Guy Brian's swan song.
Former head of major program at NASA pleads guilty
Ed Mango, the former head of a major program at NASA, has pleaded guilty in federal court to wrongdoing in the workplace.
Following yesterday's fatal Metro-North accident in The Bronx, Gov. Cuomo was front and center to address the media at the scene but Mayor Bloomberg was nowhere to be found for more than 12 hours.
NTSB Releases Photos From Scene Of Train Derailment In The Bronx
NTSB investigator Michael Flanigon inspects track at the scene of the Metro-North train derailment in the Bronx on Sunday.


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Community Recovery Services (CRS)Wisconsin's Medicaid State Plan Amendment under 1915(i) State Plan Home and Community-Based Services is called Community Recovery Services and provides three (3) specific services: Community Living Supportive Services, Supported Employment, and Peer Supports, under the umbrella of psychosocial rehabilitation.
Wisconsin's 1915(i) State Plan AmendmentCounty/Tribal CertificationCRS FAQsConsumer EligibilityIndividual Service Plan Packet GuidanceService Provider DocumentsWhat are the Service Provider Requirements? Fiscal & Admin. RelatedAdditional Information and LinksRegional Office Contact:Central Office Contact:Ron Bonlender Telephone: (608) 267-9864 Last Revised: August 08, 2013 |


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Auto Racing Challenge Just pick the 10 drivers you think will finish 1st through 10th for each race and your top 15 races count as your overall score. Win great prizes!
Birthday Club Watch NewsChannel 7 TODAY every Friday to see if you've won a Rock It Lanes gift certificate!
Fantasy Golf Contest Just pick the golfers you think will finish 1st through 10th for each of the tournaments.
Friday Night Overtime Play of the Week Contest Register or log in to cast your vote for this week's Friday Night Overtime Play of the Week! Watch NewsChannel 7 @ 6 every Wednesday to see which video won!
Pro Football Contest Just make your picks for each game of the season to win a Trip for Two to Hawaii and other great prizes!


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Click one of the color swatches below to see color-matched products.
Subscribe to our weekly email for exclusive deals, project ideas and more!
Check out our 12-Days of Christmas Sale for exclusive deals and discounts.
$6.00 $4.19
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I bought these to liven up a mini album I made for a relative, and they did a great job. Pretty designs with a great sticky backing. Love them.


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Your web-browser is very outdated, and as such, this website may not display properly. Please consider upgrading to a modern, faster and more secure browser. Click here to do so.
I met Jess Hutchinson at the League of Chicago Theatres offices to talk about how Chicago is celebrating World Theatre Day. Jess, who is the Artistic Director of New Leaf Theatre, is one of the driving forces behind Chicago's participation in WTD.
World Theatre Day is this coming Saturday, March 27. If you're here in Chicago, check out the facebook page for the celebration at the Chopin. Wherever you are, you can have a look at the map of worldwide events hosted on TCG.org.
Download with care; I have a head cold so bad that you might catch it from listening to the show…
Get the show on iTunes
Stream or download Episode 13
As always, you can email me (Uncle Sylvia) at podcastinghere at gmail dot com.


text: Volunteer / Intern : Niagara Foundation is currently offering new internship opportunities. Niagara Foundation envisions a community in which people from all walks of life interact with each other and cooperate to serve their communities, thereby strengthening civil society and promoting the development of human values. All internships are unpaid. Internships last one semester and include a 10-hour/week commitment. Applicants should email a resume and cover letter to email@example.com Applications Guidelines : Clearly indicate which internship opportunity you are applying for in your cover letter. If you are applying for more than one position, please list in order of preference. Applications that do not list the above information will not be processed. If you have any questions, please email all inquiries to email@example.com (Students interested in receiving class credit, should indicate so in their cover letters.) Qualifications: Major or general interest in community affairs; excellent research, written and oral communication skills; detailed oriented and strong organizational abilities; knowledge of Microsoft office. Internships are currently available in the following departments


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The Arizona State University Foundation manages entrepreneurial activities that benefit ASU, among them:
Arizona Technology Enterprises LLC (AzTE) is a wholly-owned subsidiary of the Arizona State University Foundation. AzTE is contracted by ASU to manage its technology venturing, and to work with university inventors and industry to transform scientific progress into products and services.
AzTE transfers technologies invented at ASU, Northern Arizona University and their affiliated research centers to the private sector by mining university research, prosecuting patents, marketing inventions and negotiating licenses. Technology transfer also facilitates ASU's efforts to attract and retain superior faculty and graduate recruitment, while returning income to the inventor and the university to support ongoing research.
SkySong is an international business and innovation center located just minutes from downtown Phoenix in Scottsdale, Arizona. Designed as a global focal point for technological innovation, cross-disciplinary collaboration and expansion of world trade, SkySong provides excellent access to major markets in the southwestern United States and Latin America. SkySong also offers the necessary environment and resources for its tenants, both international and domestic, to bring new technologies to the marketplace and expand globally.
SkySong is home to activities and organizations that comingle and stimulate new forms of global commerce, research, technology, art, education and economic development. Anchored by the iconic SkySong shade structure, its creative architecture accommodates 1.2 million square feet (112,000 square meters) of high-tech commercial office space, displays of tenants' most innovative technologies, multimedia-rich pedestrian areas, retail space, restaurants and 324 beautifully designed apartments. SkySong's tenants can live, work and play in this creative, connected enclave.
SkySong serves the needs of businesses, research and technology industry, and academia while building vital networks between university innovations, regional progress and the global technology industry. It provides businesses a competitive edge and tenants a stimulating interactive environment.
In March 2004, the Arizona State University Foundation purchased The Brickyard, an eclectic mix of three unique buildings and a parking structure located in downtown Tempe, Arizona.
Situated in the heart of downtown with the area's most popular cafes and eateries just steps away, The Brickyard is home to ASU's Ira A. Fulton School of Engineering and the School of Computing and Informatics. It also contains the Institute for Computing and Information Science and Engineering, which was created to centralize the university's key academic and research programs in computer science.
Several research centers are located in the Brickyard complex, including the Center for Cognitive Ubiquitous Computing, Decision Theater and Partnership for Research in Spatial Modeling.


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Last year, my daughter gave us, as our 30th anniversary present, a weekend at the floating Hotel "Laguna Garzón" in Maldonado, Uruguay. Unfortunately, we were not able to make use of her present even after two tries for the following reasons: First try: After having confirmed our check in date and about an hour before beginning our trip from Montevideo... More
- Reservation Options:
- TripAdvisor is proud to partner with Booking.com so you can book your Laguna Garzon Lodge reservations with confidence. We help millions of travellers each month to find the perfect hotel for both holiday and business trips, always with the best discounts and special offers.


text: is there any special meathods to knee paddling on a long board? or is it just a case of on the knees and paddle but takes some practice. i can currently paddle on my knees but if i stop paddling i fall straight off and gettign started going is also difficult so any tips would be great


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Series | Countries | Live Scores | Fixtures | Results | News |
Photos | Video & Audio | Blogs | Statistics | Archive | Games | Mobile |
Showing 1-20 | Previous | Next |
Australia v England, 2nd Test, Adelaide, 3rd day
England performance 'not good enough' - Bell
Dec 7, 2013: Ian Bell could hardly hide his frustration after seeing his England team-mates deliver another batting performance of striking incompetence
Australia v England, 2nd Test, Adelaide, 3rd day
Johnson annihilates listless England
Dec 7, 2013: Mitchell Johnson produced a blood-curdling display of world-class fast bowling to destroy England in the second Test in Adelaide. Johnson's sustained menace bore comparison with the great fast bowling spells of the modern age as he took 5 for 16 in five o
WA Chairman's XI v England XI, Perth, 3rd day
England left with much to ponder
Nov 2, 2013: England travel to Hobart with questions about the composition of their side for the first Test still largely unanswered after completing a none-too-convincing draw in their opening tour match against a Western Australia XI
WA Chairman's XI v England XI, Tour match, Perth, 2nd day
Bell, Carberry seize chance to show form
Nov 1, 2013: Ian Bell wasted no time in hitting his straps in Australia and Michael Carberry seized on the chance afforded to him by Alastair Cook's absence as England put up a solid display in their first innings of the Ashes Tour.
The Ashes 2013-14
Oct 31, 2013: It was good to get away from cricket after a hectic summer, but you soon started itching to start again. Now we are in Australia the excitement is growing ahead of a fantastic challenge
The Investec Ashes 2013
The fulfilment of a boyhood dream
Aug 28, 2013: To go unbeaten for the first time in an Ashes series since 1977, alongside players whose records will stand the test of time, is an achievement to cherish
Australia in England 2013
Cook among England players rested
Aug 27, 2013: England have rested Alastair Cook, James Anderson, Ian Bell, Graeme Swann and Stuart Broad from the ODI series against Australia after their involvement in the 3-0 Ashes victory
The Investec Ashes 2013
England knew how to seize moment
Aug 26, 2013: England's brand of cricket was not always admired during the Ashes but they able to seize the moment and produce periods of exhilarating play
The Investec Ashes 2013
Not their best, but good enough from England
Aug 26, 2013: ESPNcricinfo assesses the performances of the England players who appeared in the Ashes series
England v Australia, 5th Investec Test, The Oval, 2nd day
Aug 22, 2013: For the most part, the tension of a contest has been lacking, and listlessness has been a recurring feature
Aug 16, 2013: Despite the series scoreline, England's batting average is only 3.66 more than Australia's, which is the lowest since 1970 in a series with a margin of three of more Tests
The Investec Ashes 2013
Twenty Test hundreds makes my head spin
Aug 15, 2013: The satisfaction of being up on the charts with England's heroes and win the series
England's Walter Matthau and Jack Lemmon
Aug 14, 2013: For all their blatant differences, Bell and Pietersen are a duet as melodious in deed as in sound
England v Australia, 4th Investec Test, Durham, 4th day
A magical session, but England can get better
Aug 12, 2013: Nine wickets in a dramatic session saw England surge to a series victory, but that should not be allowed to gloss over the issues raised against Australia
Eng v Aus, 4th Investec Test, Durham, 4th day
England getting ahead 3-0 in the Ashes and Broad's best
Aug 12, 2013: Stats highlights from England's win over Australia at Durham in the Ashes
England v Australia, 4th Investec Ashes Test, Durham, 3rd day
Aug 11, 2013: With his side in trouble again, Ian Bell produced another innings to transcend the situation and write his name in the Ashes history books
England v Australia, 4th Investec Ashes Test, Durham, 3rd day
English ascendency not going to plan
Aug 11, 2013: Their top three are having the kind of series that usually sees England lose - and yet they are winning
Eng v Aus, 4th Investec Test, Chester-le-Street, 1st day
England's self-inflicted wounds
Aug 9, 2013: England's batsmen did not appear to know whether to stick or twist on the opening day, but should have followed the lead of their captain
Australia news
Clarke rises to second in batsmen rankings
Aug 6, 2013: Michael Clarke has moved up to second in the ICC Player Rankings for Test Batsmen, following his 187 in the fourth Ashes Test
England v Australia, 3rd Investec Test, Old Trafford, 3rd day
Pietersen England's most prolific
Aug 3, 2013: ESPNcricinfo presents the plays of the day from the third day at Old Trafford
Showing 1-20 | Previous | Next |


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Crystal 1200L is a left-handed, elongated corner shower cabin 1200mm x 800mm, with hand held overhead shower, body jets & more.... This model no longer available - please see the new Aqualusso Alto 04L model - Click Here
This model no longer available - please see the new Aqualusso Alto 04L model - Click Here
The Crystal 1200L from Aqualusso is a left-handed, corner (elongated) 1200mm x 800mm shower, meaning it stretches further down one of your corner walls, thus creating more space inside. Has overhead shower, hand shower with flexible hose & riser bar and 3 body jets.
The walls of the cubicle are glass and the unit also has a glass shelf inside for toiletries plus a seat which can be flipped up when not in use. Available in the tinted mirror "Storm" and glass "Ocean" finish. The Crystal series of shower cabins offers exceptional value for money by comparison to the cost of installing a conventional shower enclosure and shower system.
Ocean Finish No Longer Available. See The New Aqualusso Alto 04L
Crystal 1200L in "Ocean" Finish
Crystal 1200L in "Storm" Finish
The Crystal shower cabins for Aqualusso are an all in one solution combining, a strong acrylic low step tray, silver framework, clear 5mm glass and doors with 6mm rear glass panels.
These showers have a Thermostatic shower valve with built in diverter. The Crystal range come with all the hoses needed to operate the shower as well as WRAS approved hot and cold water hoses to connect to your water supply.
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Crystal 1200L - £549 - VAT & FREE* Delivery Included for 10 to14 Day Service.
Delivery Upgrades: Standard Delivery: 3 to 5 Working Days + £29.95. Express Service: 48 Hours + £49.95.
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Hot and Cold water supply with 15mm compression fittings, balanced 1-3 bar. Location: Free standing. Construction: 5mm acrylic tray bonded to a steel frame. Glass: 5mm Safety Glass to front and doors, 6mm to back wall glass. Frame Type: Aluminium, silver coloured.
Once your order has been received and processed, we will contact you within 24 hours by telephone, to arrange a convenient delivery day and to confirm the delivery address with you. Currently, the units come in 4 separate packages and this is supplied on a palette and will arrive on a tail-lift lorry. The delivery palette will be taken to your door, but this will depend on any access restrictions (narrow gates, passageways etc). When confirming delivery, we request that you inform us of any further restrictions, that could effect a delivery to your location where perhaps a smaller vehicle would be more suited.
Package Sizes: Carton 1: 1940mm x 110mm x 750mmCarton 2: 1220mm x 170mm x 820mmCarton 3: 1930mm x 60mm x 1040mmCarton 4: 1930mm x 165mm x 320mm
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Following delivery of your order, you are asked to check the packages upon arrival and inform us of any damage within 24 hours. Please Note: If after having confirmed a delivery date, you are not at the premises when the delivery is made, a re-delivery charge of £25 will be payable. For more detailed information regarding deliveries, please Click Here.
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Use this section to locate steam shower and shower cabin products by size and shape, style, brand name and Model number or name and all available through Smart Price Warehouse.
Corner, quadrant, elongated, rectangular etc. Low step trays and