Head and Neck Oncosurgery

Head and neck cancers comprise a wide range of malignancies of the oral cavity, food pipe (pharynx), windpipe (larynx), salivary glands, thyroid gland, nose and sinuses and skull base. Primarily, squamous cell carcinoma accounts for 90% of head and neck cancer cases. It is directly linked to many lifestyle habits, such as smoking, chewing tobacco, betel nut, consuming alcohol, etc. In addition to these lifestyle habits, exposure to human papillomavirus has also shown a strong association with oropharyngeal cancers, and even the latest trends have indicated a positive inclination trendline, especially among younger individuals. 

Treatment for head and neck cancer mainly depends upon the location of the tumour itself, the stage of cancer, and the overall health of the patient. These tumours can be managed by surgery, chemoradiation therapy, and recent advancements, such as immunotherapy. These tumours are surgically treated with or without adjuvant therapy. Therapeutic strategies having shown promising results, the key lies in early detection, timely treatment, and follow-up. Various studies and research are being undertaken in this domain to obtain precise, quick, and more personalised diagnostic and therapeutic outcomes for the patients. 

What is head and neck cancer?

The term ‘head and neck cancer’ includes a wider perspective, comprising cancers of different regions of one’s head and neck region. These are scientifically coined as ‘squamous cell carcinoma’ of the head and neck as they originate from the squamous cell lining of the mouth or pharynx. These tumours can also arise in the salivary glands, the sinuses of the nose, and muscles or nerves in the head and neck region. Unlike the head and neck tumours, these are less likely to be squamous cell carcinoma.  

1. Mouth/Buccal cavity: Regions likely to be affected with cancer include the lips, anterior two-thirds of the tongue, the bony surface on the top of the mouth (hard palate), and a small region of gum behind the wisdom teeth. 
2. A portion or entire region of the pharynx: It comprises the nasopharynx, oropharynx, and hypopharynx. 
3. A portion or entire region of the larynx 
4. Nasal and sinus cavity
5. Salivary glands
6. Thyroid glands

Squamous cell carcinoma of the head and neck can often metastasise to the neighbouring lymph nodes. Often, carcinomas of the head and neck can be left unnoticed and evident as higher cancer of the lymph node. 

What is head and neck cancer surgery?

Surgical resection remains gold standard treatment in majority of head and neck cancers. In addition, reconstruction is required which involves transfer of bone, muscle, or skin with the associated blood vessels to regain the region affected by cancer and cancer treatment. When it is impossible to attain reconstruction using self-tissue, a trained plastic surgeon may employ a custom prosthetic technique. 

The different types of head and neck cancer surgeries include: 

1. Minimally invasive head and neck surgery: These surgeries are done using endoscopes or Robotic arms. In these surgeries, minor holes are made in the region intended for surgery, and hence, the rate of recovery is faster when compared to traditional open surgeries. 
2. Transoral laser microsurgery: These are surgical interventions used to remove tumours of the larynx through the mouth. In this surgery, the surgeon visualises the cancer using a microscope and removes the tumour with the assistance of a special laser beam. The major advantage of this type of surgery is that damage to speech can be avoided, and it can be performed on an outpatient basis. It is generally safe as it does not involve external incisions. 
3. Transoral robotic surgery: This is yet another minimally invasive technique to remove oropharyngeal cancer, including cancers of the tonsils. This technique uses a combination of three-dimensional imaging with robotic surgical instruments. This technique also does not involve making any incisions. 
4. Advanced reconstruction surgery: These types of surgeries are done by a combination of a plastic surgeon and a specialised head and neck surgeon. This technique involves the transplantation of tissue from one region of the body to the tumour-affected region. 

In addition, some surgeries also include the removal of tumours with respect to the site of origin, such as:

1. Pharyngectomy: Removal of tumour from the pharynx 
2. Laryngectomy: Removal of tumour from the larynx
3. Parotidectomy: Removal of part of or entire parotid glands
4. Tracheostomy: A traditional approach for the cancers of the upper windpipe. Here, a small portion of the tumourous trachea is removed so as to create a space blocked by invading tumour 

Which types of head and neck cancers require surgical interventions?

Several head and neck cancers often warrant surgery as the ultimate treatment plan when medical or conservative treatment is not effective enough or not possible. The different types of head and neck cancers that require surgical intervention include: 

Cancers of the oral cavity: 

Cancers of the oral cavity include tumours affecting the lips, gums, or the floor of the mouth. In order to address these issues, the different surgical techniques include glossectomy (cancer of the tongue), mandibulectomy (cancer of jaws), and maxillectomy (cancer of upper jaws). A wide local excision may also be performed where some healthy tissue is removed along with tumourous tissue. The key aim of the surgery is to preserve speech and swallowing. A follow-up reconstructive surgery may be necessary. 

Cancers of the pharynx: 

The affected regions in pharyngeal cancer include the pharynx itself (throat), nasopharynx (region behind the nose), oropharynx (region in the middle of the throat), and hypopharynx (the lower region of the throat). Surgical interventions include pharyngectomy and transoral robotic surgery. Neck dissection may be necessary when tumours have spread to the lymph nodes. 

Nasopharyngeal cancer: This is the cancer of the upper portion of the throat behind the nose. For the initial stages, endoscopic intervention can be used as a minimally invasive technique to remove tumours through the nasal passages. In advanced cases, an open surgery may be necessary for the tumours situated at the base of the skull. Often, surgery is not preferred for nasopharyngeal tumours; the majority of these tumours are resolved by chemotherapy and adjuvant radiation therapy. Localised or specific regional tumours might necessitate surgery. 

Hypopharyngeal cancer: This includes cancer of the lower portion of the throat. Surgical procedures to address these tumours are partial or total pharyngectomy to remove a portion of or complete hypopharynx. For advanced stages of tumours, a procedure called laryngopharyngectomy, which is the removal of both the pharynx and larynx, may be necessary. Neck dissection is to be done if the tumours have spread to the lymph nodes. Most often, hypopharyngeal cancers are diagnosed at advanced stages, making surgery necessary. Often, surgery is combined with other treatment strategies to excise the tumour and improve survival.  

Cancers of the larynx: 

Cancers of the larynx widely affect the voice box, including the vocal cords. The major challenge of a surgeon addressing this issue is to preserve voice and swallowing. Different techniques to surgically mitigate cancers of the larynx are laryngectomy and laser surgeries to treat tumours in their early stage. Laryngectomy can be partial when a portion of the larynx is removed to preserve speech, and total, which involves the complete removal of the larynx, especially when the tumour is aggressive and when patients might necessitate stoma, an opening in the neck to breathe after the surgery. In most cases, cancers of the larynx may require reconstruction and rehabilitation. 

Cancers of the salivary gland: 

Here, the most commonly affected areas are parotids, submandibular, and sublingual glands. In order to remove these tumours, different surgical interventions used in practice are parotidectomy, submandibular gland excision, sublingual gland surgery, and facial nerve preservation surgery. A surgeon should pay attention to preserving the functions and movements of the facial gland. 

Cancers of the thyroid gland: 

Cancers of the thyroid gland are surgically addressed by thyroidectomy. When a portion of the thyroid gland is removed, the technique is referred to as lobectomy. Aggressive cases might warrant the removal of the entire thyroid gland. In such cases, a complete thyroidectomy is performed. The goal of thyroidectomy is to prevent metastasis to the surrounding tissues, especially the lymph nodes. In addition to surgery, radioactive iodine therapy is also administered to remove any remnant cancer cells.     

Metastasis to lymph nodes: 

To address for metastasis of head and neck tumours to lymph nodes, neck dissection is performed. Different surgical techniques employed are: 

• Selective neck dissection: Removal of regions in the lymph nodes that are at high risk for metastasis
• Modified neck dissection: Removal of the tumorous tissue while preserving vital muscles, nerves, and blood vessels 
• Radical neck dissection: Complete removal of all lymph nodes on one side of the neck 

What will be your journey of recovery from head and neck cancer at Fortis Healthcare?

Fortis Healthcare ensures a multidisciplinary approach to head and neck cancer treatment. We follow a sophisticated yet comprehensive approach to ensure personalised care prior to the procedure, during the procedure, and post-surgery. The healthcare team at Fortis helps you recover physically and emotionally. 

Pre-surgical care: 

The journey to recovery begins before the surgery. A thorough pre-surgical evaluation is conducted, which includes: 

• Diagnosis: Highly advanced diagnostics involve imaging studies, biopsies, and clinical evaluation in mapping the tumour site and size. 
• Multidisciplinary consultation: In the tumour board meeting, your case will be reviewed collectively by oncologists, head and neck surgeons, radiologists, and pathologists to devise an individualised treatment plan.
• Preoperative counselling: This will comprise a meeting with your surgical and oncology team to discuss what to expect in the surgery and recovery, what might happen, and what the potential risks are. 
• Mental health support: Psychological counselling is offered to assist you and your loved one in coping with the psychological impact of cancer treatment.

During the surgery: 

The head and neck cancer surgeries are done at Fortis Hospitals using state-of-the-art technology and surgical procedures. The following are what one can expect during their surgery: 

• Professional surgical care: Our experienced surgeons use traditional and minimally invasive techniques, including transoral robotic surgery (TORS) and endoscopic surgery, to remove tumours while ensuring safe preservation of speech, swallowing, and even appearance.
• Comprehensive anaesthesia and pain management: Our anaesthesiologists will see you through a comfortable and safe procedure. Overall, pain management strategies are personalised to avoid any further discomfort throughout the postoperative period.

Post-surgical care: 

Fortis Healthcare promises no compromise in post-surgical care. A dedicated team of healthcare workers will support you throughout all steps in the roadmap to your recovery. 

The post-surgical care offered are: 

• Immediate post-surgical care: You will be monitored in our dedicated recovery unit, where nurses and doctors will manage your pain, nutrition, and wound care. If you have had a complex surgery, for instance, a laryngectomy, our experts will help you get accustomed to the changes, including having a tracheostomy. 
• Rehabilitation:   
  • Speech therapy: To regain or adapt speech after laryngeal surgeries 
  • Swallowing therapy: To guide through swallowing exercises to restore regular eating habits
  • Nutritional guidance: To address challenges in one’s diet post-surgery and during recovery 
• Support for mental health: In order to address emotional challenges during the recovery, Fortis ensures timely psychological support to help you manage your mental and emotional well-being throughout the recovery. 
• Follow-up care: During the recovery process post-discharge, you will be closely monitored for regular follow-ups to evaluate disease progression and recovery rate. Adjustments to doses of chemotherapy or adjuvant medications are also done accordingly, if needed. 

Conclusion 

Head and neck cancers represent a multifaceted group of tumours, usually needing multidisciplinary care, with surgery as the primary approach. Surgery of the head and neck regions aims at removing tumours with minimal impairment of vital functions like speech and swallowing. Recovery post-surgery needs more comprehensive medical aid with physical and emotional support and physical rehabilitation therapies that help restore functions and quality of life.