Surgery for Oral Cavity and Oropharyngeal Cancer

Neck dissection

Cancers of the oral cavity and oropharynx often spread to the lymph nodes in the neck. Removing these lymph nodes (and other nearby tissues) is called a neck dissection or lymph node dissection and is done at the same time as the surgery to remove the main tumor. The goal is to remove lymph nodes proven to contain cancer. Sometimes doctors recommend an elective lymph node dissection. This may be done if there's no proof that the cancer has spread to the lymph nodes, but there's a high chance that it has based on tumor size.

In some early-stage mouth and lip cancers, a sentinel lymph node biopsy might be done to test the lymph nodes for cancer before removing them. This should only be done at treatment centers by doctors with a lot of experience in the technique.

There are several types of neck dissection procedures, and they differ in how much tissue is removed from the neck. The amount of tissue removed depends on the primary cancer’s size and how much it has spread to lymph nodes.

• In a partial or selective neck dissection only a few lymph nodes are removed.
• For a modified radical neck dissection, most lymph nodes on one side of the neck between the jaw bone and collarbone are removed, as well as some muscle and nerve tissue.
• In a radical neck dissection, nearly all nodes on one side, as well as even more muscles, nerves, and veins are removed.

The most common side effects of any neck dissection are numbness of the ear, weakness when raising the arm above the head, and weakness of the lower lip. These side effects are caused when nerves that supply these areas are damaged during the operation. After a selective neck dissection, the nerve might only be injured and can heal over time. Nerves heal slowly, but in this case, the weakness of the shoulder and lower lip may go away after a few months. If a nerve is removed as part of a radical neck dissection or because of involvement with tumor, the weakness will be permanent.

After any neck dissection procedure, physical therapy can help improve neck and shoulder movement.

Reconstructive surgery

Operations may be needed to help restore the structure of areas affected by more extensive surgeries to remove the cancer.

For small tumors, the narrow edge of normal tissue removed along with the tumor is usually small enough that reconstructive surgery isn't needed. But removing larger tumors may cause defects in the mouth, throat, or neck that will need to be repaired. Sometimes a thin slice of skin, taken from the thigh or other area, can be used to repair a small defect. This is called a skin graft.

To repair a larger defect, more tissue may be needed. A piece of muscle with or without skin may be rotated from an area close by, such as the chest (pectoralis major pedicle flap) or upper part of the back (trapezius pedicle flap).

Thanks to advances in microvascular surgery (sewing together small blood vessels under a microscope), there are many more options for reconstructing the oral cavity and oropharynx. Tissue from other areas of the body, such as the intestine, arm muscle, abdominal (belly) muscle, or lower leg bone, may be used to replace parts of the mouth, throat, or jaw bone.

Before you have extensive head and neck surgery, talk to the surgeon about your options for reconstructive surgery.

Surgery to save or restore body function

Tracheostomy

A tracheostomy or trach is a stoma (hole) made through the skin in the front of the neck and attached to the trachea (windpipe). It's done to help a person breathe.

If a lot of swelling is expected in the airway after the cancer is removed, the doctor may want to do a short-term tracheotomy (using a small plastic tube) to allow the person to breathe more easily until the swelling goes down. It stays in place for a short time, and is then removed (or reversed) when it's no longer needed.

If the cancer is blocking the throat and is too big to remove completely, an opening may be made to connect a lower part of the windpipe to a stoma (hole) in the front of the neck. This is done to bypass the tumor and allow the person to breathe more comfortably. This is called a permanent tracheostomy.

A permanent tracheostomy is also needed after a total laryngectomy.

Feeding tubes

Cancers in the oral cavity and oropharynx may keep you from swallowing enough food to stay well nourished. This can make you weak and make it harder to complete treatment. Sometimes the treatment itself can make it hard to eat enough.

A gastrostomy tube (G-tube) is a feeding tube that's put through the skin and muscle of your abdomen (belly) and right into your stomach. Sometimes this tube is placed during an operation, but often it's put in endoscopically. While you are sedated (using drugs to put you in a deep sleep), the doctor puts a long, thin, flexible tube with a camera on the end (an endoscope) down the throat to see inside the stomach. The feeding tube is then guided through the endoscope and to the outside of the body. When the feeding tube is placed through endoscopy, it's called a percutaneous endoscopic gastrostomy, or PEG tube. Once in place, it can be used to put liquid nutrition right into the stomach. As long as they can still swallow normally, people with these tubes can eat normal food, too.

PEGs can be used for as long as needed. Sometimes these tubes are used for a short time to help keep you healthy and fed during treatment. They can be removed when you can eat normally.

If the swallowing problem is likely to be only short-term, another option is to place a nasogastric feeding tube (NG tube). This tube goes in through the nose, down the esophagus, and into the stomach. Again, special liquid nutrients are put in through the tube. Some people dislike having a tube coming out of their nose, and prefer a PEG tube.

In any case, the patient and family are taught how to use the tube. After you go home, home health nurses may visit to make sure you are comfortable with tube feedings.

Dental extraction and implants

When radiation treatment is planned, a dental evaluation must be done. Depending on the radiation plan and condition of your teeth, some or even all of the teeth may need to be removed before radiation can start. The teeth may be removed either by the head and neck surgeon or an oral surgeon. If left in and exposed to radiation, teeth that are broken or infected (abscessed) are very likely to cause problems such as infections and areas of necrosis (bone death) in the jaw.

If part of the jaw bone (mandible) is removed and reconstructed with bone from another part of the body, the surgeon might place dental implants (hardware to which prosthetic teeth can be attached) in the bone. This can be done either at the same time the mandible is reconstructed or at a later date.

Surgery risks and side effects

All surgery carries risk, including blood clots, infections, complications from anesthesia, and pneumonia. These risks are generally low but are higher with more complex operations.

If the surgery is not too complex, the main side effect may be some pain afterward, which can be treated with medicines.

Surgery for cancers that are large or hard to reach may be very complicated, in which case side effects may include infection; wound breakdown; problems with eating, breathing, and speaking; or on very rare occasions death during or shortly after the procedure. Surgery also can be disfiguring, especially if bones in the face or jaw need to be removed. The surgeon’s skill is very important in minimizing these side effects, while removing all of the cancer, so it’s important to choose a surgeon with a lot of experience in these types of cancer.

Impact of glossectomy: Most people can still speak if only part of the tongue is removed, but they often notice that their speech isn’t as clear as it once was. The tongue is important in swallowing, so this may also be affected. Speech therapy can often help with these problems.

When the entire tongue is removed, patients lose the ability to speak and swallow. With reconstructive surgery and a good rehabilitation program including speech therapy, some people may regain the ability to swallow and speak well enough to be understood.

Impact of laryngectomy: Laryngectomy, the surgery that removes the voice box, leaves a person without the normal means of speech. There are several ways to restore one’s voice. See Laryngeal and Hypopharyngeal Cancer to find out more about voice restoration.

After a laryngectomy, the person breathes through a stoma (tracheostomy) placed in the front of the lower neck. Having a stoma means that the air you breathe in and out will no longer pass through your nose or mouth, which would normally help moisten, warm, and filter the air (removing dust and other particles). The air reaching the lungs will be dryer and cooler. This can irritate the lining of the breathing tubes and cause thick or crusty mucus to build up.

It's important to learn how to take care of your stoma. You will need to use a humidifier over the stoma as much as possible, especially right after the operation, until the airway lining has a chance to adjust to the drier air now reaching it. You will also need to learn how to suction out and clean your stoma to help keep your airway open. Your doctors, nurses, and other health care professionals can teach you how to care for and protect your stoma, which includes precautions to keep water from entering the windpipe while showering or bathing, as well as keeping small particles out of the windpipe.

Impact of facial bone removal: Some cancers of the head and neck are treated with operations that remove part of the facial bone structure. Because the changes that result are so visible, they can have a major effect on how people view themselves. They can also affect speech and swallowing.

It’s important to talk with your doctor about these changes before the surgery. This can help you prepare for them. You can also get an idea about what options might be available afterward. Recent advances in facial prostheses (man-made replacements) and in reconstructive surgery now give many people a more normal look and clearer speech. These things can be a great help to a person’s self-esteem.