Oral Cavity and Oropharyngeal Cancer

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Treating Oral Cavity and Oropharyngeal Cancer TOPICS

Surgery for oral cavity and oropharyngeal cancer

Several types of operations can be used to treat oral cavity and oropharyngeal cancers. Depending on where the cancer is and its stage, different operations may be used to remove the cancer.

After surgery to remove the cancer, reconstructive surgery may be used to help restore the appearance and function of the areas affected by the cancer or its treatment.

Tumor resection

In this operation, the surgeon removes (resects) the entire tumor and an area of normal-appearing tissue around it. Removing the normal tissue lessens the chance of leaving any cancer behind.

The primary tumor can be removed using a variety of approaches depending on its size and location. For example, if a tumor is in the front of the mouth, it can be removed relatively easily. Sometimes with a larger tumor, especially when it involves the oropharynx, the cancer is removed through an incision in the neck or by cutting the jaw bone with a special saw to provide access to the tumor (mandibulotomy).

Based on the location and size of the tumor, one of the operations listed here may be needed to remove it.

Mohs micrographic surgery (for some cancers of the lip)

Some cancers of the lip may be removed by Mohs surgery, also known as micrographic surgery. In this method, the tumor is removed in very thin slices. Each slice is looked at right away under the microscope to see if there are cancer cells. The surgeon continues to remove more slices until no cancer cells are seen.

This method can reduce the amount of normal tissue removed with the tumor, which limits the change in appearance the surgery causes. It requires a surgeon trained in the technique and may take more time than a standard tumor resection.

Glossectomy (removal of the tongue)

Glossectomy may be needed to treat cancer of the tongue. For smaller cancers, only part of the tongue may need to be removed (partial glossectomy). For larger cancers, the entire tongue may need to be removed (total glossectomy).

Mandibulectomy (removal of the jaw bone)

A mandibulectomy (or mandibular resection) removes all or part of the jaw bone (mandible). This operation may be needed if the tumor has grown into the jaw bone. If a tumor near the jaw is hard to move when the doctor examines the area, it often means that the cancer has grown into the jaw bone.

If the jaw bone looks normal on x-ray, and there is no evidence the cancer has spread into the jaw bone, a partial-thickness mandibular resection may be all that is needed. In this operation, also known as a marginal mandibulectomy, a piece of jaw bone is removed, but the bone is not cut all the way through.

If the x-ray shows the tumor has grown into the jaw bone, a whole portion of the mandible will need to be removed in an operation called a segmental mandibulectomy. The removed piece of the jaw can then be replaced with a piece of bone from another part of the body, such as the fibula (the smaller of the lower leg bones), hip bone, or the shoulder blade. Depending on the situation, sometimes a metal plate or a piece of bone from a deceased donor may be used instead.

Maxillectomy

If cancer has grown into the hard palate (front part of the roof of the mouth), all or part of the involved bone (maxilla) will need to be removed. This operation is called a maxillectomy or partial maxillectomy.

The hole in the roof of the mouth this operation creates can be filled with a special denture called a prosthesis. This is created by a prosthodontist, a dentist with special training.

Robotic surgery

Increasingly, trans-oral robotic surgery (TORS) is being used to resect cancers of the throat (including the oropharynx). Since the more standard, open surgeries for throat cancer can cause a number of problems, these cancers have often been treated with chemotherapy combined with radiation (called chemoradiation) over the past decade. However, newer robotic surgeries allow surgeons to remove pharynx cancers with fewer side effects. Complete resection with surgery may allow patients to avoid further treatment with radiation and/or chemotherapy. Since these procedures are newer, it is important for them to be done by surgeons (and at treatment centers) with experience in this approach.

Laryngectomy (removal of the voice box)

Very rarely, surgery to remove large tumors of the tongue or oropharynx may also require removing tissue that a person needs to swallow normally. As a result, food may enter the windpipe (trachea) and reach the lungs, where it can cause pneumonia. When this is a significant risk, sometimes the voice box (larynx) is removed together with the primary tumor. This operation is called a laryngectomy.

When the voice box is removed, the windpipe is attached to a hole (stoma) made in the skin in the front of the neck for the patient to breathe through (instead of breathing through the mouth or nose). This is known as a tracheostomy (see picture).

Losing your voice box will mean that normal speech is no longer possible, but people can learn other forms of speaking. See our document Laryngeal and Hypopharyngeal Cancer to find out more about voice restoration.

Neck dissection

Cancers of the oral cavity and oropharynx often spread to the lymph nodes in the neck. Depending on the stage and location of the cancer, it may be necessary to remove these lymph nodes (and other nearby tissues). This operation, called a neck dissection or lymph node dissection, is done at the same time as the surgery to remove the main tumor. The goal is to remove lymph nodes proven or likely to contain cancer.

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, as well as some muscle and nerve tissue are removed.
  • 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 by injury during the operation to certain nerves that supply these areas. After a selective neck dissection, the nerve might only be injured. If so, the weakness of the shoulder and lower lip usually goes away after a few months. But 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 therapists can teach the patient exercises to improve neck and shoulder movement.

Reconstructive surgery

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

For small tumors, the narrow zone of normal tissue removed along with the tumor is usually small enough that reconstructive surgery is not 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), surgeons have many more options for reconstructing the oral cavity and oropharynx. Tissue from other areas of the body, such as the intestine, arm muscle, abdominal 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, it is a good idea to ask the surgeon about your options for reconstructive surgery.

Tracheotomy/tracheostomy

A tracheotomy is an incision (hole) made through the skin in the front of the neck and into the trachea (windpipe). It is done to help a person breathe. It may be used in different circumstances.

If a lot of swelling is expected in the airway 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. It stays in place for a short time, and is then removed later when it is no longer needed.

If the cancer is blocking the throat and is too large 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 to bypass the tumor and allow the person to breathe more comfortably. This is known as a tracheostomy. A permanent tracheostomy is also needed after a total laryngectomy.

Gastrostomy tube

Cancers in the oral cavity and oropharynx may prevent you from swallowing enough food to maintain good nutrition. 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 is placed through the skin and muscle of your abdomen directly into your stomach. Sometimes this tube is placed during an operation, but often it is placed endoscopically. While the patient is sedated, the doctor passes a long thin tube with a camera on the end down the throat to see directly into the stomach. When the feeding tube is placed through endoscopy, it is called a percutaneous endoscopic gastrostomy, or PEG tube. Once in place, it can be used to deliver nutrition directly into the stomach.

Patients are fed special liquid nutrients that are dripped through the tube. As long as they can still swallow normally, patients with these tubes can also eat normal food as well.

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

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

In either case, the patient and family are taught how to use the tube. After the patient goes home, home health nurses usually visit to make sure the patient is 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 the patient’s teeth, some or even all of the teeth may need to be removed before radiation can be given. The teeth may be removed either by the head and neck surgeon or an oral surgeon. If left in, 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 exposed to radiation.

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 complicated operations.

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

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 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.

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 patients 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 our document 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 may irritate the lining of the breathing tubes and cause thick or crusty mucus to build up.

It is 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 soon 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 by 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. These surgeries can also affect speech and swallowing.

It’s important to talk with your doctor before the surgery about what these changes might be to help prepare you for them. He or she can also give you 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. Ears and noses can be made out of plastic, tinted to match the skin, and attached to the face. All of these things can be a great help to a person’s self-esteem.

More information on surgery can be found in our document Understanding Cancer Surgery: A Guide for Patients and Families.


Last Medical Review: 02/26/2013
Last Revised: 02/06/2014