Bechara Y. Ghorayeb, MD, PA
Otolaryngology-Head & Neck Surgery                                                              Phone: 713 464 2614
1140 Business Center Drive, Suite 560
Houston, TX 77043                            www.ghorayeb.com
Radical Neck Dissection
Informed Consent
Click for pictures of tracheotomy.
Neck dissection is performed in order to remove known or suspected lymph nodes containing cancer. Its purpose is to prevent further spread of that disease to other parts of the body. Over the past 50 years it has proven to be an effective method of head and neck cancer control. Complications of this surgery include wound infection and breakdown, bleeding, leakage of lymph fluid, injury to nerves controlling the lower face, throat, shoulder, tongue, diaphragm, and skin sensation under ear and jaw. Undesired effects can include shoulder weakness and pain in the neck. Most patients who have only a neck dissection are able to return to normal daily activities after healing.

I/We have been given an opportunity to ask questions about my condition, alternative forms of treatment, risks of non-treatment, the procedures to be used, and the risks and hazards involved, and I/we have sufficient information to give this informed consent. I/We certify this form has been fully explained to me/us, and I/we understand its contents. I/We understand every effort will be made to provide a positive outcome, but there are no guarantees.

Patient / Legal Guardian:______________________________________________________________________

Witness:__________________________________________________________________________________

Date:________________________________________________Time:________________________________



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