Surgery for pharyngeal cancer

Surgery is a medical procedure to examine, remove or repair tissue. Surgery, as a treatment for cancer, means removing the tumour or cancerous tissue from your body.

Most people with oropharyngeal and hypopharyngeal cancer have surgery. The type of surgery you have depends mainly on where the tumour is found in the throat, or pharynx, and where it has spread.

Nasopharyngeal cancer is rarely treated with surgery as a first treatment. It may be used for cancer that comes back (recurs) after radiation therapy and chemotherapy.

When planning surgery, your healthcare team will also consider other factors, such as your age and overall health.

Surgery may be the only treatment you have or it may be used along with other cancer treatments. You may have surgery:

• to completely remove the tumour
• to remove the lymph nodes in the neck (cervical lymph nodes) to treat or prevent the spread of cancer
• to remove as much of the tumour as possible (called debulking) before other treatments
• to reconstruct parts of the pharynx
• for placement of a feeding tube (called a gastrostomy)
• for placement of a breathing tube (called a tracheostomy)

The main goal of surgery is to completely remove the tumour, without leaving any cancer behind at the edges of the surgery (surgical margins), while also keeping your ability to breathe, swallow and speak as normally as possible after surgery. Sometimes the surgeon may need to use more than one type of surgery to reach and remove the cancer.

The following are the types of surgeries that may be done for pharyngeal cancer, listed in alphabetical order.

A gastrostomy is surgery to make an opening into the stomach. A thin, flexible feeding tube is passed directly into the stomach through the opening. A gastrostomy tube will let in food 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 pharyngeal 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 glossectomy is surgery to remove part or all of the tongue. It’s used to treat tumours that start in the base of the tongue. Itʼs also used to remove tumours that have spread to the tongue from another part of the throat. Different types of glossectomies may be used to treat pharyngeal 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 voice box (larynx). A total laryngectomy removes all of the larynx. Either a partial or total laryngectomy may be used to treat advanced pharyngeal tumours that have grown into the larynx.

A laryngopharyngectomy is a surgical procedure that combines a laryngectomy and a pharyngectomy. A laryngectomy removes part or all of the voice box (larynx). A pharyngectomy removes part or all of the throat (pharynx). 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 tumours.

A partial laryngopharyngectomy removes the part of the larynx that is affected by cancer, as well as the walls of the pharynx. It maintains as much of the normal function of the larynx as possible. 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.

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 passage in the throat that allows lung-powered speech.

Because the larynx is completely removed in a total laryngopharyngectomy, you will need to learn new ways of speaking and breathing after this surgery. You will also be offered swallowing rehabilitation that will teach you how to swallow again.

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

Partial thickness resection, also called marginal resection, removes only a part of the mandible along the top edge (margin) of the lower jawbone. Itʼs 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 pharyngeal cancer if it has spread to the roof of the mouth.

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 nasopharyngectomy is surgery to remove part of the nasopharynx. This surgery is used to treat nasopharyngeal cancer that comes back after radiation therapy. It is sometimes used to remove small tumours that have not spread beyond the nasopharynx.

A neck dissection is surgery to remove the lymph nodes in the neck (cervical lymph nodes). Most people with pharyngeal 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 pharyngeal cancer comes back 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.
• A bilateral neck dissection removes the lymph nodes on both sides of the neck. It is done when the tumour is near the centre of the pharynx or when the tumour has spread to both sides.

Find out more about neck dissection.

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.

Surgery for pharyngeal cancer may affect your ability to speak and swallow. It may also affect your appearance. Reconstructive surgery is done to improve function and appearance. It is usually done at the same time as the surgery to remove an oropharyngeal tumour, though more reconstructive surgeries may be done later if needed.

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 pharyngeal 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.

Bone grafts are used to replace the bone in the jaw that was removed during surgery. The surgeon will take bone from your ribs, hips or legs to reconstruct the jaw. Sometimes bone grafts are done with bone tissues that were donated by people after their death.

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

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

A tracheostomy is surgery to make an opening in the neck so that a small tube can be placed 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 pharyngeal cancer. The tube helps you breathe during and after the surgery. It’s 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.

Transoral resection is surgery that is done through your mouth, instead of cutting through the skin to reach the tumour. It may be done for an early-stage pharyngeal cancer that is easy to reach through your mouth. Transoral resection completely removes the tumour but has fewer side effects than having to make cuts through the skin.

You may have one of the following types of transoral resection to remove a pharyngeal 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.

Side effects of surgery will depend mainly on the type and site of surgery and your overall health. Tell your healthcare team if you have side effects that you think are from surgery. The sooner you tell them of any problems, the sooner they can suggest ways to help you deal with them.

Surgery for pharyngeal cancer may cause these side effects:

• infection
• bleeding
• blood clots
• loss of voice
• problems with breathing, shortness of breath
• coughing
• problems with speaking
• difficulty chewing
• problems swallowing
• lymphedema (swelling of the face and neck)
• feeling weak when raising your arm above your head
• ear numbness
• changes to your appearance
• low thyroid hormone (hypothyroidism)
• pain in the throat and neck area

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