Head And Neck Cancer Surgery

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Send the biopsy, the scans and a photograph of your teeth

The last of those surprises people and it should not. If radiotherapy follows the surgery, dental work has to happen before it and not after, so the state of your mouth changes the order of your entire treatment. Send the biopsy report with the p16 or HPV result if one was done, the CT or MRI of the head and neck and the chest, any PET report, a list of what you take, and a note of whether you smoke, drink, or have had radiotherapy to this area before. What comes back is an opinion on which operation fits, whether a flap is likely, and what the first three months would realistically look like. The review costs nothing and carries no obligation.

Not one disease

Head and neck cancer is an administrative category more than a diagnosis. It gathers together tumours of the mouth, the throat behind the mouth, the voice box, the space behind the nose, the sinuses and the salivary glands, and those tumours differ from one another in cause, in behaviour, in what the operation involves and in how likely you are to be cured, which means that a survival figure you find online for head and neck cancer as a whole describes a population you are almost certainly not part of, and the number that applies to you comes from the site, the stage, the p16 result and your own general health rather than from a headline. A cancer of the tonsil driven by a virus and a cancer of the tongue driven by forty years of smoking sit in the same chapter of the same textbook and share almost nothing else.

So the first useful thing anybody can tell you is where yours is.

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Two words on your pathology report change the picture more than almost anything else. If a tumour of the tonsil or the base of the tongue is p16 positive, meaning it is driven by human papillomavirus, it behaves as a distinct disease with markedly better outcomes than the same-looking tumour in a lifelong smoker, and it is staged on a separate system for exactly that reason. Look for that line. If it is absent from a report on an oropharyngeal tumour, ask why.

Surgery or radiotherapy

For most cancers described on this site the question is which operation. Here, for a substantial group of patients, the question is whether an operation is the right instrument at all, because radiotherapy can cure the same tumour without cutting anything. That comparison has been run properly, and the result is not the one a surgical department would choose to advertise.

Read that carefully, because it is easy to misread in either direction. Robotic surgery did not turn out to be the swallowing-sparing alternative it was widely assumed to be. It also did not turn out to be worse in any way that a patient would notice, and it avoids six weeks of daily radiotherapy along with the hearing loss and the dry mouth that come with it.

What tips the decision is something other than the average.

• Surgery appeals when the tumour is small and reachable through the mouth, when avoiding radiotherapy altogether looks plausible, and when you are young enough that decades of dry mouth are a real cost.
• Radiotherapy appeals when closing the defect would need a flap, when the neck disease is extensive enough that radiation is coming regardless, and when a long anaesthetic is a bad idea.
• Getting both is what everybody is trying to avoid, and it happens when the pathology after surgery turns up features that demand radiation.

So the discussion before the operation has to include a straight estimate of how likely that third outcome is for you, and a surgeon who cannot put a rough number on it has not thought about your case in enough detail.

Getting it all out

A margin is the rim of normal tissue around the tumour. In the mouth and throat there is very little room to take a generous one, since a centimetre in any direction is the difference between a tongue that works and a tongue that does not, and the surgeon is negotiating with anatomy the whole way round.

Frozen section is how that negotiation is settled during the operation, with a pathologist examining tissue while you are still asleep so that more can be taken if the edge is not clear. There are two ways of doing it and the difference between them is not a technicality.

In plain terms, checking the piece you removed finds problems that checking the empty space misses, and finding them while the patient is still on the table is the only moment when fixing them is easy. Which method a unit uses is a fair thing to ask about. A positive margin on the final report is not a catastrophe and it is not nothing. It generally means radiotherapy is added, sometimes with chemotherapy, and occasionally it means going back to take more. Perineural invasion, meaning tumour tracking along a nerve, and extranodal extension, meaning disease that has burst out of a lymph node, are the two other findings on that report that most often change the plan after the operation, and both of them are reasons to read the pathology yourself rather than accept a summary of it over the phone, since the words on the page determine what happens for the next six months and a paraphrase loses exactly the detail that decides it.

What happens to the neck

Almost every operation for a mouth or throat cancer includes an operation on the neck, and patients frequently arrive not knowing this. Scans miss small deposits in lymph nodes reliably enough that a normal-looking neck cannot be trusted.

Whether to operate on a neck that looks clear was argued about for decades until somebody settled it.

Twelve percentage points of survival is about as decisive as surgical trials get, and it explains why the neck is now cleared routinely rather than watched. Modern neck dissection is selective, meaning the surgeon removes the specific groups of nodes that this particular tumour drains into and leaves alone the muscle, the large vein and the nerve that older radical operations sacrificed. The nerve that lifts your shoulder runs through the field and is preserved, though it is frequently bruised, which produces a stiff and aching shoulder for some months and responds well to physiotherapy started early rather than started once the stiffness has set in, which is the mistake most people make with it. Shoulder exercises begin in the first fortnight and continue for months, and they are boring in a way that makes them easy to abandon. Numbness of the ear lobe and the skin of the neck is expected and permanent in patches.

For very small oral cancers, sentinel node biopsy offers a smaller version of the same thing, tracing the first node the tumour drains into and clearing the rest of the neck only if that node is involved. Whether that is offered to you depends on the size and site of the tumour and on whether the unit performs enough of them to be good at it, and that is a question to put directly.

The second operation

Here is the part most pages skip. When a defect is too large to close directly, tissue is taken from somewhere else on your body, moved to the head with its artery and vein, and plumbed into vessels in the neck under a microscope. That is a free flap, and it is a second full operation performed by a second team, frequently at the same time as the first so that the total anaesthetic stays reasonable.

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Roughly nineteen flaps in twenty are entirely uneventful. When one does fail the operation is not over and the reconstruction is redone with different tissue, which lengthens everything.

Donor sites deserve more attention than they get, because nobody warns patients about them properly. A forearm flap leaves a skin graft and a scar you will see every day. A fibula flap leaves a leg that needs a fortnight before it walks confidently. Ask what the donor site will look like and how it will feel, and ask before the operation.

Speech, swallowing and the team behind them

Whether you speak clearly and eat normally in a year depends on the surgeon, and it depends nearly as much on people whose names most patients never learn.

Speech and language therapists assess you before the operation, so that afterwards there is something to compare against, and they run the swallowing rehabilitation that decides how quickly the feeding tube comes out. Dietitians keep your weight up during a period when eating is difficult and calories matter more than they ever have. Dentists check your mouth before radiotherapy, because a tooth extracted after radiation heals badly and can lead to the jawbone dying, which is a far worse problem than losing the tooth early would have been. A unit without those three services is not a head and neck unit. Meet the speech therapist before you agree to anything, because the quality of that conversation tells you more about where you have landed than any brochure will, and a therapist who cannot describe what your swallowing rehabilitation will consist of week by week is a warning about the whole department.

There is good news, and it belongs to the smaller operations.

Notice what that last sentence identifies. The operation on the tumour was not what cost these patients function. The additional treatment was, which is one more argument for catching these cancers small and one more reason the added radiotherapy question matters so much at the planning stage.

Larger resections are a different conversation and an honest one has to include that some function is permanently changed. What surgery and rehabilitation together are aiming at is a mouth that manages ordinary food and speech that strangers understand on the telephone, and for most patients with reconstructed tongues and jaws that target is reached.

The first week

Patients find the first week harder to picture than the operation itself, so here it is plainly.

1. You wake with a tracheostomy if the mouth or throat has been operated on extensively, because swelling makes the airway unreliable for a few days. It comes out again in the great majority of cases. You cannot speak through it initially, and writing or a phone is how you communicate.
2. A feeding tube through the nose delivers nutrition while the reconstruction heals and swallowing is unsafe. Uncomfortable, yes. Permanent, no.
3. Drains sit in the neck for several days, and the flap is checked hourly around the clock by somebody who will wake you to do it.
4. Sitting up and walking start on day one or two even with all of that attached, because chest infections and clots are the complications that actually threaten people at this stage.
5. A speaking valve goes on within the first week, and the tracheostomy comes out shortly after that, once the swelling settles enough for the airway to look after itself.

Swelling of the face and neck peaks around days two to four. It alarms families who were not warned. It settles, and the face you see at three weeks is not the face you saw at three days.

Pain falls short of what people expect after an operation of this size, and the dominant complaints are the tube in the nose, the inability to speak and thirst, in that order, which is not what anybody prepares for. Anyone travelling with you should know all of this before they walk into the room, because their reaction in the first forty-eight hours affects you more than anybody plans for.

What follows the surgery

The pathology report arrives about a week to ten days after the operation, and it decides whether anything else is needed.

When radiotherapy is added

Positive or very close margins, several involved nodes, disease that has broken out of a node, perineural invasion or a deeply invasive primary all point towards radiotherapy afterwards, and extranodal extension or a positive margin brings chemotherapy alongside it. Treatment starts around six weeks after surgery. It then runs daily for six weeks. Waiting longer than about six weeks to start is associated with worse control, which matters enormously if you are travelling and have to arrange it at home.

What radiotherapy costs you

Dry mouth is the lasting one and it is more disruptive than it sounds, affecting taste, sleep, dental health and the pleasure of eating for years. Sore throat, thickened saliva, fatigue and a skin reaction dominate the six weeks themselves, and the fatigue in particular arrives late, deepens through the final fortnight and takes a couple of months after the last session to lift properly. Swallowing needs active work during treatment and afterwards, because muscles that stop being used stiffen, and the therapists will push you to keep swallowing through the worst of it precisely for that reason, which feels unreasonable at the time and is the single intervention that most reliably separates people who eat normally at a year from people who do not. All of which argues that the surgical plan and the radiotherapy plan should be made together, at the same meeting, by people who are both in the room, since a surgeon planning a resection without knowing whether radiation is coming afterwards is planning half an operation.

How long you stay

Three to five weeks in the country for anything involving a flap, and two to three weeks for a smaller resection with neck dissection. These are the longest stays of any operation described on this site, because the reconstruction has to prove itself and the swallowing has to be re-established before you get on an aeroplane.

Assessment runs four to seven days. Examination under anaesthetic with biopsies where the extent is unclear, cross-sectional imaging of the head, neck and chest, a PET scan in selected cases, vessel imaging of the donor site for a flap, dental assessment, speech and swallowing baseline, nutritional assessment and a multidisciplinary meeting. That meeting is the point of the whole week and it should include a radiation oncologist in the room rather than consulted afterwards by letter, since the decision about what happens after the operation shapes what the operation itself should be. The hospital stay runs seven to fourteen days for a flap reconstruction, with the first two or three in a high dependency setting, and three to five days for a smaller operation. Then one to two weeks nearby. That fortnight covers the wound checks, the removal of drains and tubes, the pathology discussion that determines whether radiotherapy is coming, and the first sessions of swallowing therapy with somebody who will still be reachable by video call after you fly. None of that week is idle and very little of it compresses, so book your flights around this timetable and not around an optimistic estimate somebody gave you on the telephone.

When you are cleared to fly

Flying is cleared once the wounds are dry, the tracheostomy is out and closed, the flap is stable and you are taking enough nutrition by mouth or through a tube you can manage yourself. For a straightforward flap that is around two and a half to three weeks. Anybody flying with a tracheostomy still in place needs the airline told in advance, along with equipment and an escort. All of that is arrangeable. None of it is arrangeable the day before.

What drives the cost

Of every operation on this site, this one produces the widest spread, and two patients with the same diagnosis can end up in genuinely different places. Eight things account for most of the spread.

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The parts that sit outside the surgical figure

Adjuvant radiotherapy or chemoradiotherapy is a separate course of treatment lasting six weeks, and where you have it is a decision in itself. Speech and swallowing therapy continues for months and is the part left out of a quotation most consistently, even though it is running long after the surgical bill has been settled and it is doing more for your daily life at that point than anything else on the list. Nutritional support, dental restoration and, for some, a voice prosthesis after laryngectomy carry on well past the point where the surgical episode is formally closed. Packages here ordinarily cover the transfers, the assessment week, the operating fees for both teams, the stated hospital and high dependency nights, an interpreter, accommodation and the appointments before you leave. Outside them sit the flights, insurance, additional nights, the treatment of a complication, radiotherapy and everything named in the sentences above it, which taken together can amount to a larger sum than the operation, spread across a longer period and paid in instalments nobody quotes for. Find out early where the radiotherapy is expected to happen, because the answer changes the arithmetic completely and it is the question that goes unasked most consistently until the pathology report has already arrived.

Six questions to ask before you accept a figure

Does the figure assume a flap, and what happens to it if the frozen section forces a larger resection than planned. How many hospital nights and how many high dependency nights are included, and what an additional night costs. Is a return to theatre for flap trouble covered. Are speech therapy and dietetic input included for the whole of the stay rather than as a single visit. Is the dental assessment included, and any extraction that follows from it. And is radiotherapy quoted at all, or assumed to be happening somewhere else.

Nothing here means anything until a surgeon has seen your scans and your pathology. That review is free, and it is the only thing that turns a website number into a number about you.

Once you are home

Follow-up here is closer than for most cancers, because recurrences in this region are found by a doctor putting a scope through the nose and looking rather than by a scan. Expect review every one to two months through the first two years, stretching to twice yearly and then annually out to five years, which is a demanding schedule to run from another country and is the single practical detail most worth settling before you travel rather than after. A baseline scan three months after treatment finishes is standard, giving everybody a picture to measure future ones against, and imaging after that is driven by symptoms or by something felt on examination.

Five documents should travel home with you, in English, since your care will be run from them by people who were not in the room.

• The operative note, naming what was removed, which flap was used and which neck levels were cleared.
• The full pathology, with margins in millimetres, perineural invasion, node counts and extranodal extension stated explicitly.
• The multidisciplinary recommendation on radiotherapy, stating plainly the date by which treatment should have started.
• The speech and swallowing assessment, with the exercises you were given.
• The dental report, with anything that needs doing before radiation.

Two things need reporting quickly wherever you are. Any new lump, ulcer that fails to heal within three weeks, persistent pain in one ear or change in voice, all of which are how recurrence announces itself. And jaw pain or exposed bone after radiotherapy, which needs assessing promptly rather than watched. Get in touch here for either, and for anything about the flap, the tube feeding or the swallowing exercises.

Stopping smoking and stopping alcohol change your odds of a second cancer more than any drug anybody can offer you. That is a blunt thing to put on a hospital page. It is also the truest sentence in this article, and the one most likely to still matter in ten years.

Frequently asked questions about head and neck cancer surgery