Head and Neck Cancer Surgery

Surgery is one of the primary treatment modalities for head and neck cancer and, for many cancers of the oral cavity and selected other sites, the preferred first-line intervention. The fundamental goals of head and neck cancer surgery are to achieve complete removal of the tumor with clear margins, to address regional lymph node disease in the neck, and – wherever oncologically safe – to preserve the structures responsible for speech, swallowing, breathing, and appearance.

Modern head and neck surgical practice has evolved considerably. Advances in surgical technique, instrumentation, and reconstructive methods have expanded organ-preservation options and improved functional outcomes, allowing many patients to undergo effective tumor removal with significantly reduced impact on quality of life compared with historical approaches.

The decision to proceed with surgery – and the specific procedures chosen – is made by a multidisciplinary team and is guided by the location and stage of the tumor, the histological type, the patient's overall health, and the likely functional impact of the planned procedure.

[Pre-operative evaluation]

Before surgery, a comprehensive workup is conducted to confirm the diagnosis, characterize the extent of disease, and assess the patient's fitness for major surgery under general anesthesia. This typically includes:

• Review of all biopsy and pathology results
• CT, MRI, and/or PET-CT imaging of the head, neck, and chest
• Cardiovascular and pulmonary evaluation
• Blood tests
• Dental evaluation
• Speech and swallowing baseline assessment
• Nutritional assessment

[Patient instructions]

Standard pre-operative instructions apply:

• Fasting from midnight the night before surgery (nothing to eat or drink)
• Temporary discontinuation of certain medications as directed by the surgical team
• Smoking cessation is strongly encouraged before surgery, as tobacco use impairs wound healing and increases complication risk

In the operating room

• Head and neck cancer surgery is performed under general anesthesia. Depending on the location and extent of the tumor, endotracheal intubation may not be possible, and a tracheostomy (a surgical airway created through the front of the neck) may be placed at the start of the procedure to secure the airway during surgery.
• The surgical team removes the primary tumor with a margin of normal tissue around it to reduce the risk of local recurrence. Frozen section analysis – intraoperative examination of tissue margins by a pathologist – guides the extent of resection. Surgery often proceeds simultaneously at the primary tumor site and the neck.

Common surgical procedures in head and neck cancer:
Primary tumor resection

Excision of the tumor from its site of origin. The approach varies by tumor location:

• Transoral excision: Used for accessible oral cavity and small oropharyngeal tumors; no external incisions required
• Transoral laser microsurgery (TLM): Laser-assisted resection under operating microscope, introduced through the mouth; used for selected laryngeal, hypopharyngeal, and oral tumors
• Open resection: Required for larger or more posteriorly located tumors; involves an external incision in the neck or, when necessary, temporary division of the mandible (mandibulotomy) to improve surgical access

Glossectomy

Surgical removal of the tongue, performed for tongue cancer:

• Partial glossectomy: Removal of a portion of the tongue
• Hemiglossectomy: Removal of approximately half the tongue
• Total glossectomy: Complete removal of the tongue, reserved for advanced cases; reconstructive surgery is required, and a concurrent laryngectomy may be performed to prevent aspiration

Mandibulectomy

• Partial or complete removal of the mandible (lower jawbone) when the tumor involves the bone. A marginal mandibulectomy removes only the superior cortex; a segmental mandibulectomy removes a full-thickness segment and requires reconstruction with a bone-containing free flap (typically the fibula).

Maxillectomy

• Removal of part or all of the maxilla (upper jaw / hard palate) for tumors involving the hard palate, upper gingiva, or paranasal sinuses. A surgical obturator prosthesis is placed to close the resulting defect and restore speech and swallowing.

Laryngectomy

Surgical removal of the larynx (voice box):

• Partial laryngectomy: Various procedures that remove only the affected portion of the larynx, preserving the remaining structures and some voice function; includes supraglottic laryngectomy, supracricoid laryngectomy, and endoscopic laser resection
• Total laryngectomy: Complete removal of the entire larynx; the trachea is permanently redirected to a stoma (opening) in front of the neck for breathing; voice is permanently affected and rehabilitation is required

Parotidectomy

• Surgical removal of the parotid gland. A superficial parotidectomy removes the tissue superficial to the facial nerve; a total parotidectomy removes the entire gland. The facial nerve is carefully identified and preserved whenever oncologically possible.

Neck dissection

Systematic removal of lymph node-bearing tissue from the neck, performed to address lymph node metastasis or to obtain pathological staging information. There are three principal types:

• Selective neck dissection: Removal of specific lymph node levels most likely to harbor metastasis from a given primary site; preserves major non-lymphatic structures
• Modified radical neck dissection: Removal of all five cervical lymph node levels while preserving one or more major non-lymphatic structures
• Radical neck dissection: Removal of all five lymph node levels together with the sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve; reserved for cases with direct tumor involvement of these structures

Tracheostomy

• It creates a surgical opening in the anterior trachea to secure or bypass the upper airway. It may be temporary (removed once healing is complete and swelling resolves) or permanent (following total laryngectomy).

Duration and hospitalization

• The duration of surgery varies considerably – from less than one hour for a small transoral excision to 10–14 hours or more when extensive resection is combined with free flap reconstruction. Post-operative hospital stays typically range from three to ten days for resection-only procedures, and up to two weeks or more when complex reconstruction is performed.

All surgical procedures carry inherent risks. Specific risks associated with head and neck cancer surgery include:

• Bleeding (hemorrhage): Intraoperative or post-operative bleeding; post-operative hemorrhage may occur after surgery and requires urgent evaluation
  
  
• Infection: Wound infection or deep-space neck infection; antibiotic prophylaxis is routinely administered
  
  
• Wound dehiscence or fistula formation: Failure of wound healing, or development of a salivary fistula (leakage of saliva through the wound) – more common following prior radiation therapy
  
  
• Nerve injury: Depending on tumor location and proximity to critical nerves, injury to the facial nerve, spinal accessory nerve (causing shoulder weakness), hypoglossal nerve (tongue function), marginal mandibular branch (lower lip movement), or recurrent laryngeal nerve (vocal cord function) may occur
  
  
• Dysphagia and aspiration: Swallowing difficulty and aspiration risk are common after operations involving the tongue, oropharynx, or larynx; speech-language pathology rehabilitation is an integral part of recovery
  
  
• Tracheostomy-related complications: Mucus plugging, infection, or accidental decannulation if a temporary tracheostomy tube is in place
  
  
• Flap-related complications (if reconstruction is performed): Resulted from vascular compromise of the reconstructed tissue
  
  
• Shoulder dysfunction: Following neck dissection with sacrifice or manipulation of the spinal accessory nerve
  
  
• General anesthetic risks: Standard risks of major surgery under general anesthesia, including thromboembolic events, pulmonary complications, and cardiovascular events

The primary outcome measure of head and neck cancer surgery is the adequacy of tumor resection – specifically, the achievement of clear surgical margins. Final pathological analysis of the resected specimen confirms margin status, the histological grade of the tumor, the number of lymph nodes examined and involved, and the presence of adverse pathological features that may indicate the need for adjuvant treatment.

Post-operative adjuvant therapy

• Patients with adverse pathological features are typically referred for post-operative radiation therapy, with or without concurrent chemotherapy, beginning approximately four to six weeks after surgery once wound healing is adequate.

Rehabilitation

Recovery from head and neck cancer surgery often involves multidisciplinary rehabilitation:

• Swallowing rehabilitation: Speech-language pathology evaluation and therapy to restore safe and functional swallowing
• Voice rehabilitation: Following laryngectomy, patients work with a speech-language pathologist to develop an alternative means of voice communication
• Physical therapy: Shoulder and neck exercise programs for patients who develop dysfunction after neck dissection
• Nutritional support: Dietitian guidance during the period of impaired oral intake

Surveillance

• After completing treatment, regular follow-up examinations are scheduled to detect early recurrence. The frequency of follow-up is highest in the first two years and gradually decreases over subsequent years.