Surgery for oropharyngeal and oral cavity cancer
lip cancer symptoms
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Various types of operations can be used to treat cancers of the oral cavity and the oropharynx. Depending on the location of the cancer and its stage, different operations can be used to remove the cancer.
After removing the cancer, reconstructive surgery can be used to help restore the appearance and function of the areas affected by the cancer or its treatment.
Resection of the tumor
In a resection of the tumor, the entire tumor and an area of surrounding tissue of normal appearance are removed (resected). The area of normal tissue is removed to reduce the likelihood of leaving any cancer cells.
The main tumor is removed using a method determined by its size and location. For example, if a tumor is in the front of the mouth, it can be removed with relative ease through the opening of the mouth. However, sometimes, with a larger tumor (especially when it has expanded into the oropharynx), it needs to be removed by incision in the neck or by cutting the jaw bone with a special saw to gain access to the tumor (mandibulectomy).
Depending on the location and size of the tumor, one of the operations below may be needed to remove it.
Mohs micrographic surgery (for some types of lip cancer)
Some types of lip cancer can be removed by Mohs surgery, also known as micrographic surgery. The tumor is removed in very thin layers. Each layer is examined immediately with a microscope to see if there are cancer cells. More layers are removed and examined until no cancer cells are seen.
This method can reduce the amount of normal tissue that is removed with the tumor and limits the change in appearance caused by surgery. A surgeon trained in this technique is required and may take longer than conventional tumor resection.
Glossectomy (removal of the tongue)
Glossectomy may be necessary to treat cancer of the tongue. For smaller cancers, it may only be necessary to remove part of the tongue (partial glossectomy). In the case of larger cancers, it may be necessary to remove the entire tongue (total glossectomy).Mandibulectomy (removal of the jaw bone)
For a mandibulectomy (or mandibular resection), the surgeon removes all or part of the jaw bone. This operation may be necessary if the tumor has grown inside the jaw. If it is difficult to move a tumor near the jaw when the doctor examines the area, this often means that the cancer has grown in the jaw.
If the jaw looks normal in imaging studies and there is no evidence that the cancer has spread to the jaw, it may not be necessary to cut the bone completely. In this operation, also known as partial mandibular thickness resection or marginal mandibulectomy, the surgeon removes only part of the jaw.
If the x-ray shows that the tumor has grown inside the jaw, it will be necessary to remove an entire section of the jaw in an operation called segmental mandibulectomy. The section of the jaw that is removed can then be replaced with a section of bone from another part of the body, such as the fibula (the smallest of the lower bones of the leg), the hip bone or the scapula. Instead of this, depending on the situation, it may sometimes be necessary to use a metal plate or bone section from a deceased donor.
Maxilectomy
If the cancer has spread to the hard palate (front of the roof of the mouth), it will be necessary to remove all or part of the involved bone (maxilla). This operation is called a maxillectomy or partial maxillectomy.
The hole in the roof of the mouth that is created with the operation can be filled with a special denture called a prosthesis. The prosthesis is made by a prosthodontist, who is a dentist with special training.
Robotic surgery
Increasingly transoral robotic surgery has been used to remove cancers of the throat (including the oropharynx). Because more conventional open surgeries for throat cancer can cause a number of problems, these cancers have often been treated with chemotherapy combined with radiation (chemoradiation) over the past few decades. However, the latest robotic surgeries allow surgeons to completely remove pharyngeal cancers with fewer side effects. It is possible that patients whose cancers are completely removed may avoid additional treatments with radiation, chemotherapy, or both. Because these procedures are more recent, it is important that they are performed by surgeons (and in treatment centers) with experience in this technique.
Laryngectomy (extirpation of the vocal organ)
Very rarely, in surgery to remove large tumors in the tongue or oropharynx it may also be necessary to remove the tissue a person needs to swallow normally. As a result, food can pass into the windpipe and into the lungs, which can cause pneumonia. When this represents a significant risk, the vocal organ (larynx) is sometimes removed during the same operation that is done to remove the cancer. The removal of the larynx is called a laryngectomy.
When the larynx is removed, the trachea joins a hole (stoma) that is made in the skin in front of the neck for the patient to breathe (instead of through the mouth or nose). This is called a tracheotomy (see picture).
Once the speech organ is lost, normal speech is no longer possible, although people can learn other ways of speaking. Read our document Cancer of the larynx and hypopharynx to find more information on the restoration of the voice.Dissection of the neck
Oral cavity cancer and oropharyngeal cancer usually spread to the lymph nodes in the neck. The removal of these lymph nodes (and other adjacent tissues) is known as neck dissection, or lymph node dissection, and is performed at the same time as surgery to remove the main tumor. The goal is to remove lymph nodes that have or may have cancer.
There are several types of neck dissection procedures and they differ with respect to the amount of neck tissue that is removed. The amount of tissue removed depends on the size of the primary cancer and how much it has spread to the lymph nodes.
In a partial or selective dissection of the neck only a few lymph nodes are removed.
In a modified radical neck dissection, most of the lymph nodes on one side of the neck are removed between the jaw and the clavicle, as well as part of the muscle and nerve tissue.
In a radical neck dissection, almost all the lymph nodes on one side are removed, as well as more muscles, nerves and veins.
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 by the injury caused by the operation to certain nerves that affect these areas. After a selective dissection of the neck, it is possible that only the nerve has been affected. If so, the weakness of the shoulder and lower lip will usually disappear after a few months. However, if a nerve is removed as part of a radical neck dissection or because it was committed to the tumor, the weakness will be permanent.
After any neck dissection procedure, the physiotherapist can teach the patient some exercises to improve neck and shoulder mobility.
Reconstructive surgery
It may be necessary to perform operations to help restore the structure or function of the areas affected by more extensive surgeries performed to remove the cancer.
For small tumors, the narrow area of normal tissue that is removed along with the tumor is usually small enough that reconstruction is not needed. However, removal of larger tumors can cause defects in the mouth, throat or neck that will need repair. Occasionally, a small layer of skin, taken from the thigh or other area, may be used to repair a small defect. This is called a skin graft.
To repair a larger defect, more tissue may be needed. You can alternate a muscle part with or without skin from a nearby area, such as the chest (pectoralis pedicled flap) or the upper back (pedicled trapezius flap).
Thanks to advances in microvascular surgery (suture of small blood vessels under the microscope), there are many more options for the reconstruction of the oral cavity and the oropharynx. Tissues from other areas of the body, such as the intestine, arm muscles, abdominal muscles, or lower leg bone, can be used to replace parts of the mouth, throat, or jaw.
Before you undergo extensive head and neck surgery, it is good to ask the surgeon about your options for reconstructive surgery.
Tracheostomy / tracheostomy
A tracheotomy is an incision (orifice) that is made through the skin that is in front of the neck and towards the trachea. This procedure is done to help a person breathe. It can be used in several different circumstances.
If a lot of airway swelling is expected after the cancer is removed, the doctor may want to do a temporary tracheotomy (using a small plastic tube) to allow the person to breathe more easily until the swelling goes down . The tracheotomy stays for a short period of time, and then it is removed when it is no longer needed.
If the cancer blocks the throat and is too large to be removed completely, it is possible to make an opening to connect the lower part of the trachea to a stoma (hole) in the front of your neck to derive the tumor and allow it to the person breathe more comfortably. This is called a tracheostomy.
A permanent tracheostomy may also be needed after a total laryngectomy.Gastrostomy tube
Cancers of the oral cavity and oropharynx can prevent swallowing enough food to maintain good nutrition. This problem can weaken you and make it harder for you to finish the treatment. Sometimes, the treatment itself can make it harder to eat enough food.
A gastrostomy tube (G tube) is a feeding tube that is placed through the skin and muscle of your abdomen directly into your stomach. Sometimes, this tube is placed during an operation, but it is often placed endoscopically. While the patient is sedated, the doctor passes a long, thin, flexible tube that has a camera on the end (an endoscope) down the throat to look directly into the stomach. The procedure of placing a feeding tube through an endoscopy is called percutaneous endoscopic gastrostomy, or PEG tube. Once placed, it can be used to administer nutrition directly to the stomach.
Patients are fed with special liquid nutrients as a drip through a tube. Whenever they can swallow normally, patients with these tubes can also eat normal foods.
PEGs can be used to feed a patient as needed. Sometimes, these tubes are used for a short period of time to help keep a patient healthy and nourished during treatment. In addition, they are easily removed when the patient can eat normally.
If the problem of swallowing is probably only short-term, another option is to place a nasogastric feeding tube (NG tube). This tube is inserted through the nose, down the esophagus to the stomach. Likewise, the feeding is carried out by means of a drip with special liquid nutrients through a tube. Some patients dislike having a tube coming out through the nose, and prefer GEP.
In either case, the patient and the family are taught how to use the tube. After the patient goes home, they are usually visited by home care nurses to make sure the patient is comfortable with feeding through these tubes.
Extraction and dental implants
When planning a radiation treatment, a dental evaluation must be performed. Depending on the radiation plan and the condition of the patient's teeth, it may be necessary to remove some or even all of the teeth before supplying the radiation. The head and neck surgeon or an oral surgeon can perform the extraction of the teeth. If left and exposed to radiation, broken or infected teeth (with abscesses) are very likely to cause problems (such as infections and areas of necrosis [bone death] in the jaw).
If part of the jaw is removed and reconstructed with bone from another part of the body, the surgeon can place dental implants (metallic material to which the prosthetic teeth can be fixed) in the bone. This procedure can be carried out at the same time as the jaw is reconstructed or at a later date.
Risks and side effects of surgery
All surgery carries risks, including blood clots, infections, complications of anesthesia and pneumonia. In general, these risks are low, but higher with more complicated operations.
If the surgery is not too complex, the main side effect may be some pain after the procedure, which can be treated with medicines if necessary.
Surgery for cancers that are large or hard to reach can be very complicated, in which case, side effects can include infection, spontaneous opening of the wound, eating or talking problems or in very rare cases, death during the procedure or shortly after it. In addition, surgery can cause disfigurement, especially if it is necessary to remove the bones from the face or jaw. The surgeon's skill in removing all cancer is very important to minimize these side effects. Therefore, it is very important to select a surgeon with a lot of experience in these types of cancer.
Impact of glossectomy: most people who have only a part of their tongue removed can talk; however, they often notice that their speech is not as clear as it used to be. The tongue is important to swallow so that this function can also be affected. Often, language therapy can 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 patients may regain the ability to swallow and talk enough to be understood.
Effects of laryngectomy: laryngectomy, surgery that removes the larynx, leaves people without the normal means of speech. There are several ways to restore a person's voice. Read our document Cancer of the larynx and hypopharynx to find more information on the restoration of the voice.
After a laryngectomy, the person breathes through a stoma (tracheostomy) located in front of the lower part of the neck. When a stoma is made, this means that the air you inhaled and exhaled will no longer pass through your nose or mouth, which would normally help to moisten, warm and filter the air (removing dust and other particles). The air that reaches the lungs will be colder and drier. This can cause irritation of the lining of the respiratory tract and accumulation of thick or crusted mucus.
It is important to learn about the care of your stoma. You will need to use a humidifier on the stoma as much as possible, especially shortly after the operation, until the airway lining has a chance to adjust to the drier air they now receive. You will also need to learn how to do the suction and cleaning of your stoma to help keep your airway open. Your doctors, nurses, and other health professionals can teach you how to perform these tasks and how to protect your stoma, including precautions to prevent water from passing into the windpipe while bathing, as well as preventing small particles from entering the trachea.
Effects of facial bone removal: Some types of head and neck cancers are treated with operations that remove part of the bony structure of the face. Since the changes caused by this surgery are so visible, they can have a greater effect on how people see themselves. They can also affect speech and swallowing.
It is important to talk with your doctor before surgery to find out what changes are expected so that you can be prepared. Your doctor can also give you an idea about the options that may be available after the procedure. The latest advances in facial prostheses (artificial replacements) and reconstructive surgery currently provide many people with a more normal appearance and clearer speech. You can make ears and plastic noses, which are dyed to match the color of the skin and adhere to the face. All these things can be very helpful for a person's self-esteem.
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