Surgery for head and neck cancers

Removing lymph nodes

If the cancer has spread to the lymph nodes in your neck, or it is very likely to spread, your surgeon will probably remove some lymph nodes. This operation is called a neck dissection or lymphadenectomy. Your surgeon will tell you if this is needed and explain the procedure. 

Most often, lymph nodes are removed from one side of the neck, but sometimes they need to be removed from both sides. A neck dissection may be the only surgery needed, or it may be part of a longer head and neck operation. The surgeon will make a cut under your jaw and sometimes down the side of your neck. You will often have a small tube (drain) in your neck to remove fluids from the wound for a few days after the surgery. A neck dissection may affect how your shoulder moves and your neck looks after surgery. A physiotherapist can help improve movement and function.

How the surgery is done

Depending on the type of head and neck cancer you have, different surgical methods may be used to remove the cancer. Each method has advantages in particular situations – your doctor will advise which method is most suitable for you. 

Your surgical options for head and neck cancers may include: 

• endoscopic surgery – the surgeon inserts a rigid instrument with a light and camera through the nose or mouth to see and remove some cancers, particularly cancers from the nose and sinuses 
• transoral laser microsurgery (TLM) – a microscope (usually with a laser attached) is used through the mouth to remove cancers, particularly of the larynx and lower throat 
• transoral robotic surgery (TORS) – the surgeon uses a 3D telescope and instruments attached to robotic arms to reach the cancer through the mouth; often used for oropharyngeal cancers
• open surgery – the surgeon makes cuts in the skin of the head and neck to remove cancers; used for larger cancers and those in difficult positions. Part of the upper and lower jaw or skull may need to be removed and then replaced or reconstructed. 

Minimally invasive surgery such as endoscopic, TLM and TORS may mean less scarring, a shorter hospital stay and faster recovery. However, these types of surgery are not suitable for all cases, and open surgery is often the best option.

Reconstructive surgery

Surgery for oral cancer

The type of surgery used depends on the cancer’s size and location. Localised cancers can be treated by removing part of the tongue, mouth or lip. For larger cancers, the surgery will affect a bigger area and you may need reconstructive surgery to continue to chew, swallow or speak. 

Some tumours can be removed through the mouth, but you may need open surgery for larger tumours. Different types of oral surgery include: 

• glossectomy – removes part or all of the tongue
• mandibulectomy – removes part or all of the lower jaw (mandible) 
• maxillectomy – removes part or all of the upper jaw (maxilla).

Surgery for pharyngeal cancer

Pharyngeal cancers are treated differently depending on which part of  the pharynx is affected. Surgery can be used for many oropharyngeal  and hypopharyngeal cancers. Nasopharyngeal cancers are rarely  treated with surgery. They may be treated with chemotherapy (often  before radiation therapy), radiation therapy (for early-stage cancers), or chemoradiation.

Small oropharyngeal and hypopharyngeal cancers can often be  treated with minimally invasive surgery, which is sometimes followed  by radiation therapy with or without chemotherapy. If the cancer is  large or advanced and surgery is an option, it is more likely to be  open surgery through a cut in the neck. Surgery is often followed  with radiation therapy and possibly chemotherapy. If surgery is not  possible due to the size or location of the tumour, radiation therapy or chemoradiation is usually given instead.

Different types of pharyngeal surgery include:

• hypopharyngectomy – removes part of the hypopharynx (lower throat)
• pharyngolaryngectomy – removes all of the larynx and part of 
  the pharynx; this surgery is less common and is similar to a total 
  laryngectomy (see below)
• oropharyngectomy – a less common surgery that removes some of 
  the oropharynx (the part of the throat behind the mouth).

Surgery for laryngeal cancer

If laryngeal cancer is at an early stage, you may have surgery to remove part of the larynx (partial laryngectomy). The surgery may be minimally invasive or open. Your voice may be hoarse or weak afterwards, and may take up to 6 months to recover. In some cases, the changes to the voice may be permanent.

If the cancer has advanced and chemoradiation isn’t an option, you may need open surgery to remove the larynx (total laryngectomy). This operation removes the whole larynx and separates the windpipe (trachea) from the food pipe (oesophagus). After this surgery, you will breathe through a hole in the front of your neck called a laryngectomy stoma. This is a permanent change and you will no longer be able to breathe through your nose and mouth. Because this surgery removes the voice box, you won’t be able to speak in the same way. These changes can be hard to adjust to. A speech pathologist will teach you new ways to talk and communicate.

If you have a total laryngectomy, part or all of your thyroid gland may be removed (thyroidectomy). The thyroid produces thyroxine (T4), the hormone that controls your metabolism, energy levels and weight, so you may need to take thyroid hormone replacement tablets every day for the rest of your life. Talk to your doctor about this.

Surgery for nasal or paranasal sinus cancer

Your doctor may advise you to have surgery for nasal or paranasal sinus cancer if the tumour isn’t too close to your brain or major blood vessels. The type of surgery will depend on where the tumour is and, if you have paranasal sinus cancer, which sinuses are affected. You will often need to have reconstructive surgery as well.

Nasal and sinus cancers are often close to the eye socket, brain, cheekbones and nose. Your surgeon will talk to you about the most suitable approach and whether any other parts of the head or neck may need to be removed to get the best outcome.

The surgeon will also consider how the operation will affect how you look, and your ability to breathe, speak, chew and swallow.

Different types of surgery for nasal and sinus cancer include:

• maxillectomy – removes part or all of the upper jaw (maxilla); may 
  include the upper teeth, part of the eye socket and/or the nasal cavity
• skull base surgery – also known as a craniofacial resection, this 
  surgery removes part of the nasal cavity or sinuses; often done 
  endoscopically through the nose, but a cut along the side of the nose may be needed; sometimes a neurosurgeon assists with this surgery
• orbital exenteration – removes the eye and may also remove tissue 
  around the eye socket
• rhinectomy – removes part or all of the nose.

If your nose, or a part of it, is removed, you may need to have an  artificial nose (prosthesis) or the nose may be reconstructed using tissue from other parts of your body. The process for completing the prosthetic or reconstructed nose may take several months. Your surgeon will give you more information about the process and how  long this is likely to take. A prosthetic eye may also be an option.

Surgery for salivary gland cancer

Most salivary gland tumours affect one of the parotid glands, which sit in front of the ears. Surgery to remove part or all of a parotid gland is called a parotidectomy.

The facial nerve runs through the parotid gland. This nerve controls facial expressions and movement of the eyelid and lip. If the facial nerve is damaged during surgery, you may be unable to smile, frown or close your eyes. This is known as facial palsy, and it will usually improve over several months. 

In some cases, the facial nerve needs to be cut so the cancer can be removed. This will affect how your face looks and moves.

There are various procedures that can help improve this, such as using a nerve from another part of the body (nerve graft). 

If the cancer affects a gland under the lower jaw (submandibular gland) or under the tongue (sublingual gland), the gland will be removed, along with some surrounding tissue. Nerves controlling the tongue and lower part of the face may be damaged, which may cause some loss of function (e.g. how you speak, eat or close your mouth).

Side effects of surgery

Most surgeries for head and neck cancer will have some short-term side effects, such as discomfort and a sore throat. Recovery after a larger surgery may be more challenging, especially at first.

Depending on the type of surgery you’ve had, after a period of recovery, you may not have any ongoing issues. However, some people do need to adjust to permanent changes after head and neck surgery. 

Long-term side effects can include: 

• reduced energy levels
• difficulty eating (e.g. chewing or problems with teeth)
• speech changes
• breathing changes
• change in appearance 
• changes to intimacy and your sex life
• vision and hearing changes
• pain, numbness, swelling (lymphoedema) or less movement in the area.

Ask your treatment team about what side effects you can expect. Tell them if you experience any side effects that worry you or are ongoing. 

What to expect after surgery

How you will feel after head and neck cancer surgery will vary greatly depending on your age, your general health, the size of the affected area and whether you also have reconstructive surgery. Your surgeon can give you a better idea of what to expect after the operation. The side effects listed below are often temporary.

Pain
You will have some pain and discomfort for several days after surgery, but you will be given pain medicines to manage this. You may take tablets or be given injections, or you may have patient-controlled analgesia (PCA), which delivers a measured dose of pain medicine through a drip when you press a button. You may also have numbness after surgery.

Eating and drinking
You will usually wake up from surgery with a drip in your arm to give you fluids. You usually won’t be allowed to eat or drink for several hours or sometimes days. Depending on the surgery, you may then start with clear  liquids,move on to puréed food, and then soft foods. 

Drains and catheters
For a few days, you may have tubes at the surgery site to drain fluid from the wound into small containers. You may also have a catheter, a tube from your bladder that drains urine into a bag.

Feeding tube
Eating and drinking may be difficult after some surgeries. A temporary feeding tube may be inserted through your nose into your stomach (nasogastric or NG tube) to allow the surgery area to heal. Another option is a gastrostomy or PEG or RIG tube inserted directly into your stomach. A nutritional formula is then given through these feeding tubes.

Movement
After some surgeries, you may be in bed for a time. A physiotherapist will teach you breathing exercises to help clear your lungs and reduce the risk of a chest infection. As soon as possible, your team will encourage you to sit in a chair and walk around. This will speed up recovery.

Breathing difficulties
If surgery is likely to cause your mouth, tongue or throat to become swollen, your surgeon will talk to you about having a temporary tracheostomy. This is a breathing tube in your neck that helps you to breathe.

Speech changes
Some surgeries may affect your ability to speak clearly, but your team will discuss this with you beforehand. You will usually see a speech pathologist who will help you improve your speech. 

Sore throat
It’s common to have a sore throat after mouth or throat surgery, but you will be given medicine to control any pain. You may also have some throat discomfort from the anaesthetic tube for a few days.

Swallowing
Surgery will sometimes change the way you swallow and this can often be difficult at first. A speech pathologist will assess your swallowing and help you regain your ability to swallow.