Surgery for oropharyngeal cancer

Surgery may be used to treat oropharyngeal cancer. The type of surgery you have depends mainly on the size and location of the tumour and the 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 oropharynx
• place a feeding tube (called a gastrostomy)
• place a breathing tube (called a tracheostomy)

The following types of surgery are used to treat oropharyngeal 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 surgical resection is surgery to remove the tumour along with a margin of healthy tissue around it.

A minimally invasive surgery called transoral resection is now being used instead of open surgical resection to remove some oropharyngeal tumours. Minimally invasive means that large cuts aren’t needed to reach and remove a tumour. Transoral resection completely removes the tumour but has fewer side effects than surgical resection. This means there may be less need for further treatment with radiation therapy or chemoradiation.

You may have one of the following types of transoral resection to remove an oropharyngeal tumour.

• Transoral robotic surgery (TORS) uses an endoscope to see the tumour in the throat and a computer-based system to guide the surgical tools to remove the tumour.
• Transoral laser microsurgery (TLM) uses an endoscope to see the tumour. The endoscope is connected to a laser and the laser is used to remove the tumour.

A tonsillectomy is surgery to remove the tonsils. It may be used to treat advanced oropharyngeal cancer that may have grown into the tonsils.

A glossectomy is surgery to remove part or all of the tongue. It is used to treat tumours that start in the base of the tongue. It is also used to remove tumours that have spread to the tongue from another part of the pharynx (throat). Different types of glossectomy may be used to treat oropharyngeal cancer.

• A partial glossectomy removes only part of the tongue and may be used to treat smaller tumours.
• A total glossectomy removes the whole tongue and is used to treat large tumours. Reconstructive surgery will be done after a total glossectomy to help improve swallowing and speech.

A partial laryngectomy is surgery to remove part of the larynx (voice box). A total laryngectomy removes all of the larynx. Either a partial or total laryngectomy may be used to treat advanced oropharyngeal tumours that have grown into the larynx.

A mandibulectomy is surgery to remove part of the lower jawbone (mandible). It is used to remove a tumour that is near or has spread (metastasized) to the jawbone. Different types of mandibulectomy may be used to treat oropharyngeal cancer.

Partial thickness resection, also called marginal resection, removes only a part of the mandible along the top edge (margin) of the lower jawbone. It is used when the tumour is near the mandible or has grown into the membrane that covers the bone (called the periosteum).

Full thickness resection, also called segmental resection, removes an entire section of the lower jawbone. It may be done when the tumour has grown deeper into the bone. The surgeon will need to rebuild the jawbone after this surgery.

A maxillectomy is surgery to remove part or all of the upper jawbone (maxilla). The maxilla also forms the roof of the mouth (the hard palate). A maxillectomy is used to treat oropharyngeal cancer if it has spread to the roof of the mouth and a large part of the maxilla needs to be removed.

Reconstructive surgery can be done to rebuild the tissues that are removed. Depending on how much of the hard palate is removed, you may need a prosthesis to form the roof of the mouth.

A palatal resection is surgery to remove and rebuild part of the hard palate, soft palate or both. It is used to treat cancer in the roof of the mouth.

A neck dissection is surgery to remove cervical lymph nodes. Most people with oropharyngeal cancer will have a neck dissection. A neck dissection may be used when cancer in the cervical lymph nodes doesn’t respond to radiation therapy or chemotherapy. A neck dissection may also be done if oropharyngeal cancer comes back (recurs) in the cervical 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 the primary tumour started in a tonsil or the tumour is only on one side of the neck, the surgeon will usually only remove lymph nodes on the same side of the neck as the tumour.

If the tumour is near the centre of the oropharynx or has spread to both sides, the surgeon will remove the lymph nodes on both sides of the neck. This surgery is called bilateral neck dissection. It is done when it is possible that the tumour has spread to both sides.

Find out more about neck dissection.

Salvage surgery may be done to remove cancer that remains after chemoradiation or radiation therapy.

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 oropharyngeal 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 oropharyngeal cancer. The tube helps you breathe during and after the surgery. It is removed after the swelling goes down and you can breathe without difficulty.

If you have a partial laryngectomy, you may have a temporary tracheostomy tube. If you have a total laryngectomy, the tracheostomy will be permanent. You will breathe through a hole (stoma) in your neck.

Surgery for oropharyngeal cancer may affect your ability to speak and swallow. It may also affect your appearance. Reconstructive surgery may be done to improve function and appearance. It is usually done at the same time as the surgery to remove an oropharyngeal 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 oropharyngeal 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 front of 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.

Side effects can happen with any type of treatment for oropharyngeal 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 oropharyngeal cancer may cause these side effects:

• loss of voice
• difficulty speaking
• difficulty chewing
• difficulty swallowing
• feeling weak when raising your arm above your head
• numbness of the ear
• 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.