Surgery for hypopharyngeal cancer

Surgery is sometimes used to treat hypopharyngeal cancer. The type of surgery you have depends mainly on the size and location of the tumour and stage of the cancer. When planning surgery, your healthcare team will also consider other factors, such as your age and overall heath.

Surgery may be done for different reasons. You may have surgery to:

• completely remove the tumour while allowing you to speak, swallow and breathe as normally as possible
• remove the lymph nodes in the neck (cervical lymph nodes) to treat or prevent the spread of cancer
• remove as much of the tumour as possible (called debulking) before other treatments
• reconstruct parts of the hypopharynx
• place a feeding tube (called a gastrostomy)
• place a breathing tube (called a tracheostomy)

Most people have a full dental exam before surgery for hypopharyngeal cancer.

The following types of surgery are used to treat hypopharyngeal cancer. You may also have other treatments before or after surgery. Sometimes the surgeon may need to use more than one type of surgery to reach and remove as much of the cancer as possible.

A laryngopharyngectomy is a surgical procedure that combines a laryngectomy and a pharyngectomy. A laryngectomy removes part or all of the larynx (voice box). A pharyngectomy removes part or all of the pharynx (throat). During the surgery, part of the esophagus may also be removed (called an esophagectomy). The esophagus is the tube that leads from the pharynx to the stomach.

Depending on the location and size of the tumour and how far the cancer has spread (metastasized), you may have a partial or a total laryngopharyngectomy to treat hypopharyngeal cancer.

A partial laryngopharyngectomy is used to maintain as much of the normal function of the larynx as possible. It removes the part of the larynx that is affected by cancer, as well as the walls of the pharynx. A partial laryngopharyngectomy is rarely done for hypopharyngeal cancer because the cancer is usually found at an advanced stage.

After a partial laryngopharyngectomy, rehabilitation for speech and swallowing is offered. Even if the vocal cords are removed during surgery, other parts in the larynx can be used to speak.

The type of partial laryngopharyngectomy you have depends on where the tumour started in the hypopharynx and which part of the larynx the tumour has grown into.

A total laryngopharyngectomy completely removes the larynx, its supporting structures and the walls of the pharynx. All or part of the thyroid may also be removed.

A total laryngopharyngectomy may be done if:

• the tumour stops the vocal cords from moving
• the cancer has spread to the cartilage of the larynx or thyroid, to the thyroid, to the base of the tongue or to other soft tissues of the neck

A near-total laryngopharyngectomy is sometimes done instead of a total laryngopharyngectomy. This leaves some structures in place and creates a permanent shunt that allows lung-powered speech.

Because the larynx is completely removed during a total laryngopharyngectomy, people who have this surgery will need to learn new ways of speaking and breathing. They will also be offered swallowing rehabilitation.

A total laryngopharyngectomy with an esophagectomy completely removes the larynx, the walls of the pharynx and the upper part of the esophagus (called the cervical esophagus). It is used when the tumour has spread to the upper part of the esophagus.

A neck dissection is surgery to remove lymph nodes in the neck (cervical lymph nodes). A neck dissection for hypopharyngeal cancer is done during a laryngopharyngectomy. It may also be done after radiation therapy if there are still cancer cells in the lymph nodes.

Depending on which lymph nodes the cancer has spread to, you may have one of the following types of neck dissection. Each type removes a different amount of tissue.

• A selective neck dissection, also called a partial neck dissection, removes only the lymph nodes closest to the site of the primary tumour.
• A modified radical neck dissection removes the lymph nodes from one side of the neck between the jaw and collarbone, along with some muscle and nerve tissue.
• A radical neck dissection removes nearly all the lymph nodes from one side of the neck, along with more muscle, nerve tissue and veins. If a radical neck dissection has to be done on both sides of the neck, the surgeon may do 2 different surgeries to prevent complications. One of the jugular veins will not be removed or the surgeon will rebuild it.

If the cancer has spread to both sides of the neck, lymph nodes are removed from both sides of the neck. This surgery is called a bilateral neck dissection. Hypopharyngeal tumours tend to spread to both sides of the neck.

Find out more about neck dissections.

A gastrostomy is surgery to make an opening into the stomach. A thin, flexible feeding tube is passed directly into the stomach through the gastrostomy opening. A gastrostomy tube will let in foods and liquids (called enteral feeding) when you find it too difficult to eat or drink.

You may need a gastrostomy tube if you are going to have radiation therapy or surgery for hypopharyngeal cancer. These treatments can cause the throat to swell and make it difficult or painful to eat or drink. The surgeon may place a gastrostomy tube before radiation therapy starts to make sure you can have good nutrition during treatment. Most of the time, a gastrostomy tube is only needed for a short period of time.

A tracheostomy is surgery to make an opening in the neck and place a small tube into the trachea (windpipe) to help you breathe. After a tracheostomy, you will breathe through this tube. This surgery may be done if a tumour or swelling after surgery makes it difficult for you to breathe normally.

The surgeon may place a temporary tracheostomy tube during surgery for hypopharyngeal cancer. The tube helps you breathe during and after the surgery. It is removed after the swelling subsides and you can breathe without difficulty.

If you have a partial pharyngectomy, the tracheostomy will be temporary. If you have a total pharyngectomy, the tracheostomy will be permanent.

Surgery for hypopharyngeal cancer may affect your ability to speak and swallow. It may also affect your appearance. Reconstructive surgery may be done to improve the look and function of the mouth and neck as much as possible. It is usually done at the same time as surgery to remove the hypopharyngeal tumour.

A skin graft is a piece of healthy skin taken from one part of the body (called the donor site) and placed over the area where the cancer was removed.

Skin grafts used in reconstructive surgery for hypopharyngeal cancer are usually split-thickness grafts. The surgeon uses a special tool to remove the outer layer of skin (epidermis) and part of the inner layer of skin (dermis) from the donor site. The donor site is often the upper leg. The skin from the donor site is then placed over the surgical wound.

Flaps are used to repair larger wounds. A flap is a piece of tissue that may include muscle, skin, fat and bone. A flap has its own blood supply. One end of the tissue is cut away from the body, while the other end remains attached to the body. The flap is placed over the wound and stitched in place.

A free flap uses a piece of tissue that has been completely removed from the donor site and moved to the wound site. The surgeon then connects the tiny blood vessels of the flap to the vessels of the wound site. This type of surgery is known as microvascular surgery.

Some common donor sites for flaps include the forearms, legs, back, chest and abdomen.

You may need reconstruction with a small intestine free flap if the walls of the hypopharynx are removed along with the tumour. The surgeon uses a piece of the small intestine to replace the section of hypopharynx that was removed.

The surgeon may do a gastric pull-up if the upper part of the esophagus is removed during surgery to treat hypopharyngeal cancer. The surgeon pulls the rest of the esophagus and the stomach up and connects the pharynx to what remains of the esophagus.

Side effects can happen with any type of treatment for hypopharyngeal cancer, but everyone’s experience is different. Some people have many side effects. Other people have only a few side effects.

If you develop side effects, they can happen any time during, immediately after or a few days or weeks after surgery. Sometimes late side effects develop months or years after surgery. Most side effects will go away on their own or can be treated, but some may last a long time or become permanent.

Side effects of surgery will depend mainly on the type of surgery and your overall health.

Surgery for hypopharyngeal cancer may cause these side effects:

• loss of voice
• difficulty speaking
• difficulty swallowing
• feeling weak when raising your arm above your head
• facial disfigurement
• low thyroid hormone (hypothyroidism)
• pain
• infection

Tell your healthcare team if you have these side effects or others you think might be from surgery. The sooner you tell them of any problems, the sooner they can suggest ways to help you deal with them.

Find out more about surgery and side effects of surgery. To make the decisions that are right for you, ask your healthcare team questions about surgery.