Head and Neck Cancer Surgery: Reconstruction and Voice

Modern head and neck cancer surgery removes the tumour while protecting speech, swallowing and appearance. The advances that make this possible include microvascular free flap reconstruction planned with 3D-printed templates, transoral laser and robotic surgery, intraoperative nerve monitoring, near-infrared imaging of the parathyroid glands, preoperative embolisation of vascular tumours, and voice rehabilitation after laryngectomy with a voice prosthesis, an electrolarynx or oesophageal speech.

Dr. Priyanka Raina, Senior Consultant (Head & Neck Surgery) - Surgical Oncology, Artemis Hospitals, Gurugram, India, presented a series of cases showing how each technique changes the result for the patient. Her starting point is that these advances are surgeon-friendly and, adopted properly, give patients the best results. This article follows her cases from the skull base to the larynx. The diagnostic and staging work that precedes surgery is covered in the article on diagnosis, staging and treatment, and the full overview is in the complete guide to head and neck oncology.

Skull base resection for a giant craniofacial osteosarcoma

A woman around thirty years of age presented with a very large osteosarcoma (a bone cancer) of the left craniofacial region. The swelling had begun during pregnancy and worsened sharply after delivery; by the time she reached Dr. Raina's team she had complete dysphagia and severe pain. PET-CT showed the tumour extending to the skull base, involving the entire mandible and part of the maxilla.

She had already received two to three cycles of neoadjuvant chemotherapy without an adequate response, so the multidisciplinary team decided on surgery. The tumour was resected with clearance at the skull base; the specimen measured roughly 12 by 12 by 12 centimetres. Pathology confirmed clear margins. Radiotherapy was to follow. For Dr. Raina, the measure of the case was not only the resection but the patient's quality of life afterwards, given how much pain and swallowing difficulty she had before surgery.

Carotid body tumour surgery: embolise first

A carotid body tumour is a highly vascular tumour at the fork of the carotid artery in the neck. Dr. Raina's protocol is embolisation of the tumour's blood supply before surgery. Practice on this varies between centres: meta-analyses disagree on whether preoperative embolisation reduces blood loss. She presented a woman in her late fifties with a large left-sided carotid body tumour classified as Shamblin II (partly surrounding the carotid vessels). After embolisation, imaging on the table showed a dramatic fall in the tumour's vascularity, and the tumour was then removed with a good postoperative result.

In the Q&A, Dr. Raina added that every carotid body tumour her team has treated has been benign. They have also operated on Shamblin III tumours, which encase the vessels, working with the cardiothoracic and vascular surgeons in the team. The patient she presented needed only one day of ICU observation and was discharged after three to four days. Complications can be avoided, she said, when the preoperative steps are complete: embolisation, a preoperative angiogram and assessment of the circle of Willis, the arterial ring that supplies the brain. Cost guidance is on the embolisation cost page.

Parotid surgery with facial nerve monitoring

The facial nerve runs through the parotid gland, and injury to it paralyses the face. Dr. Raina's team uses intraoperative nerve monitoring in parotid and thyroid surgery. Electrodes are placed over the muscles supplied by the nerve's branches, from the temporal and zygomatic branches to the marginal mandibular and cervical branches. A handheld stimulator then confirms each branch during the dissection, and the monitor displays the response at every point, before the surgeon reaches the nerve and as the tumour is separated from it.

Her example was a young woman with adenoid cystic carcinoma of the parotid who was so afraid of facial paralysis that she had decided to live with the tumour rather than risk her face. It took time to persuade her that the nerve could be preserved. With monitoring, every branch was saved, and the immediate postoperative result showed preserved movement of the eyes and lips.

Preserving nerves: the basics

Asked how her team preserves neurovascular bundles so consistently, Dr. Raina gave a deliberately simple answer. Nerve monitoring helps, but the foundation is visibility: very good surgical loupes, or the microscope. In parotid surgery she also routinely applies steroids to the operated bed at the end of the operation and has seen a good nerve response, though she is still collecting data on this practice. It is not an established standard: trials of perioperative steroids in parotid surgery have given mixed results.

Thyroid and parathyroid surgery

Large retrosternal goitre

Removing a very large thyroid that extends behind the breastbone (a retrosternal goitre) is achievable; preserving the surrounding structures while doing so is the real challenge. Dr. Raina presented an elderly woman, wheelchair-bound because of a spinal condition, who was struggling to breathe because of a huge retrosternal thyroid. The gland was removed through the neck, and she returned home in a relatively healthy state. Cost guidance is on the thyroidectomy cost page.

Minimally invasive thyroidectomy

For selected patients, Dr. Raina's team uses a minimally invasive endoscopic approach to thyroidectomy. Her criteria are a nodule of about 2 centimetres or smaller, preferably benign. In malignant disease, achieving complete oncologic clearance through an endoscope is more difficult.

Finding the parathyroids with near-infrared light

The parathyroid glands, which control blood calcium, are small and easily injured during thyroid surgery. Dr. Raina's team uses near-infrared autofluorescence imaging: an infrared camera in the operating theatre makes the parathyroid glands glow on screen, so they can be located and preserved. The technique is most useful in large multinodular goitres and retrosternal extension, where the anatomy is distorted. Her team is preparing a research paper on its use.

Head and neck cancer surgery with free fibula reconstruction

A composite oral resection, often called a "commando" operation, removes the tumour together with part of the jaw. Dr. Raina presented a man in his late sixties whose tongue cancer had completely involved the mandible. He underwent near-total glossectomy (removal of most of the tongue) with segmental mandibulectomy (removal of a section of the jaw), reconstructed with a free fibula flap: bone from the lower leg transferred with its blood supply and joined to vessels in the neck. Despite losing almost the entire mandible and tongue, he is doing very well. Cost guidance for this kind of operation is on the tumour excision surgery cost page.

Planning with 3D-printed templates

To plan these reconstructions, her team uses computer-aided design and 3D printing. Without templates, the surgeon must judge freehand how to cut and shape the fibula and how to route the perforator vessel that supplies the skin paddle. Printed cutting guides make the operation faster and more precise, and they allow the position of dental implants to be planned so that the patient can receive dental rehabilitation in the same operation.

Transoral robotic surgery (TORS) for head and neck cancer

Transoral robotic surgery (TORS) removes tumours through the open mouth, without external incisions. Dr. Raina was candid that its role in head and neck cancer is limited. Her team uses it mainly for oropharyngeal and supraglottic cancers, and has begun using it in some thyroid surgeries and neck dissections. In oropharyngeal cancer the results are very good: robotic resection supports treatment de-escalation, and some patients need no adjuvant treatment afterwards. Omitting adjuvant treatment depends on low-risk pathology, and wider de-escalation is still being evaluated in clinical trials.

Voice after laryngectomy: rehabilitation options

Complex laryngectomy

For advanced laryngeal cancer, Dr. Raina presented a man in his seventies who had tried alternative medicines before accepting surgery. His operation removed the entire larynx, part of the pharynx and the overlying skin, and the defect was reconstructed with a pectoralis major myocutaneous (PMMC) flap, a flap of chest muscle and skin. After surgery he reported that he was eating well and smiled when asked how he was coping.

Three ways to restore a voice

After laryngectomy the patient breathes through a stoma in the neck and loses the natural voice. Dr. Raina offers three routes, and the patient chooses:

1. Tracheo-oesophageal voice prosthesis. A small one-way valve is placed in a puncture between the trachea and the oesophagus, either at the time of laryngectomy or as a secondary procedure. Air from the lungs is diverted through the valve to vibrate the throat tissues.
2. Electrolarynx. A handheld device held against the neck produces sound. Newer models are more patient-friendly.
3. Oesophageal speech. A speech and swallowing therapist trains the patient to produce voice from swallowed air.

For patients who refuse further surgery, the electrolarynx and oesophageal speech remain fully non-surgical options.

How well a voice prosthesis works after laryngectomy

In the Q&A, Dr. Raina described the latest generation of voice prostheses as very clinician-friendly. Once the puncture has been made in theatre, the prosthesis can be placed in an outpatient clinic, a minor theatre or even a dressing room. Many patients learn to speak with it immediately; others need two to three sessions of speech therapy. Patients learn to clean, use and occlude the device themselves in front of a mirror.

The voice quality is the main advantage. An electrolarynx produces a mechanical, robotic sound; speech through a tracheo-oesophageal prosthesis is close to the patient's natural voice.

The drawbacks are real, and she discusses them before surgery:

• Device life and replacement. She described the expected device life as only 6 months, although in many of her patients the prosthesis lasts beyond 2 years. Published series report a median device life of roughly three to seven months, with wide variation between patients. For patients who travelled far for cancer treatment, returning to replace it is costly and logistically difficult.
• Leakage. Most patients need postoperative radiotherapy or have already been irradiated, and many need a flap. Where the tissue may break down or a leak may develop, she generally avoids a voice prosthesis, because a leak is very troublesome to manage.
• Follow-up. A prosthesis suits patients who can stay in close follow-up with a practitioner able to manage it; otherwise case selection must be strict.

Development is rapid. Dr. Raina has seen two new generations of voice prostheses in the last four years, newer designs carry an extra seal against leakage, and laryngeal transplantation remains at the experimental stage. Her hope is a device that is completely hands-free and leak-proof. For her, the true reward of these advances is a patient who eats and speaks without feeling any compromise in daily life.

The full exchange on voice prostheses and nerve preservation is on the Live Discussion page, and Dr. Raina's fellowship training in microvascular reconstruction is listed on her profile. Before surgery, the red flags and referral pathway determine how early these patients reach a surgical team.