Management of Cancer of the Head and Neck
Surgery: General Guidelines

Although an increasing percentage of patients with squamous cell cancer of the Head and Neck (HNSCC) can be treated with radiation alone or radiation and chemotherapy, many still require surgery as either the definitive initial treatment or for salvage of primary treatment failure. The specific operative approaches will be detailed in subsequent chapters of these guidelines. It is the purpose of this chapter to summarize the surgical principles appropriate for all patients undergoing head and neck cancer surgery.

In order to decide among alternative treatment options, the operability of a tumor needs to be assessed. Operability is a subjective term. One must assess the anatomic extent of a tumor, the functional consequences of its resection, the presence or absence of distant metastases, and comorbid conditions that might determine the patient's ability to tolerate the contemplated surgery. As a rule, partial resection of a tumor leaving gross disease behind does not benefit the patient. If the initial evaluation suggests that the anatomic extent of a tumor makes complete removal impossible, surgery should not be undertaken. With the possible exception of certain slowly growing salivary malignancies and well-differentiated thyroid cancer, surgery should not be undertaken if distant metastases are present. Anatomic resectability is not synonymous with operability. A patient with medical conditions precluding extensive surgery or a patient unwilling or unable to accept the functional consequences of a proposed surgical procedure should be considered inoperable.

There is no such thing as a routine preoperative evaluation. All patients with HNSCC should have a chest x-ray to evaluate the possibility of metastatic disease or a second primary lung malignancy. The routine performance of triple endoscopy (laryngoscopy, bronchoscopy, esophagoscopy) has been proposed because of the risk of occult second primary malignancies. The larynx can usually be adequately evaluated in the office. The yield of esophagoscopy and bronchoscopy in asymptomatic patients is so low that these should not be considered mandatory although they are performed in some institutions as a matter of local preference. Multiple imaging studies searching for distant metastases in the absence of symptoms are not indicated.

Patients undergoing head and neck surgery can be admitted to the hospital the morning of surgery. Any preoperative evaluation can be done as an outpatient. While most procedures require overnight hospitalization, small intraoral excisions can be performed as an outpatient. Intraoperative monitoring is determined by the extent of the surgical procedure and coexisting medical problems. A single peripheral intravenous catheter is adequate for most procedures. Routine central venous pressure monitoring or right heart catheterization and pulmonary artery pressure monitoring are not required even in the most extensive resections and reconstructions unless major blood loss is anticipated or the patient has serious underlying heart disease. The insertion of an arterial catheter to monitor blood pressure and provide access for arterial blood gas measurement is convenient in complex, prolonged operations. Indwelling urinary catheters are recommended if the anticipated length of surgery is more than 4 hours.

Care should be taken to avoid the administration of large volumes of intravenous fluids particularly during prolonged procedures. Patients undergoing head and neck surgery do not require the same volume of fluids as patients undergoing laparotomy or thoracotomy. The administration of large volumes of fluid can result in inappropriate ADH secretion, pulmonary problems, and prolonged hospital stay. Beyond the replacement of preoperative deficits and intraoperative losses, 250 cc -- 350 cc per hour of crystalloid is usually sufficient. Hourly urinary outputs of 10 cc -- 20 cc in the absence of other signs of hypovolemia are generally adequate. Attempts to maintain a greater urinary output can result in serious fluid overload.

The upper aerodigestive tract is colonized by a broad spectrum of aerobic and anaerobic bacteria. In procedures in which the surgical wound is contaminated by saliva, the use of prophylactic antibiotics is mandatory. Many different single or combination drug regimens have been demonstrated to be equally effective if they provide anaerobic coverage. Antibiotics should be commenced immediately before the start of surgery. There is no benefit to their continuation after the first post-operative day. Prophylactic antibiotics are not required in clean surgical procedures such as radical neck dissection, thyroidectomy, etc.

The techniques required for head and neck surgical procedures are similar to those in other types of surgery. The choice of cutting instruments (knife, scissors, electric cautery, laser, etc.) is a matter of individual preference. There is no data to suggest that one instrument is better than another in most situations. Meticulous hemostasis is important to permit adequate visualization of anatomic structures, avoid unnecessary blood loss and transfusion, and avoid postoperative hematomas that can become secondarily infected. Most radical head and neck procedures can be performed without the need for blood transfusions. Devitalized tissue should be resected to avoid suture line dehiscence and wound infection. Because of the elevation of skin flaps during neck dissection and because of the large potential spaces created by extensive resections and reconstructions, many patients require the placement of closed, suction drains at the conclusion of surgery. These drains are generally removed several days postoperatively when the daily drainage falls below 40 cc -- 50 cc. It is not necessary for patients to be hospitalized until drains are removed. Patients can be taught to empty the drainage canisters and measure the daily drainage or this can be performed by visiting nurses. Suction drains can be safely removed in the office.

The extent of surgery is determined by the need to remove the tumor with a margin of normal tissue, while preserving function whenever possible. In some situations (partial laryngectomy, selective neck dissection) the extent of surgery is determined by the anatomy of the structure resected. In others (partial glossectomy, mandibulectomy) there is no anatomic basis for the size of the resection. The minimal resection that provides adequate margins is sufficient. It is difficult to define what determines an "adequate margin". It is important to remember that while the staging system measures tumors in only two dimensions, cancers grow in three dimensions. A resection that is adequate for a superficial 2 cm cancer of the tongue is totally inadequate for a tumor measuring 2 cm in diameter and 2 cm thick even though they are the same stage. Adequate margins in all three dimensions are mandatory. While negative margins do not guarantee cure, microscopically positive margins result in an unacceptably high local recurrence rate in most studies. Margins of 1 cm to 2 cm are usually adequate. In some situations, smaller margins may be accepted to preserve function if they are microscopically free of disease.

Postoperatively, most head and neck patients are hemodynamically stable. After the usual length of time in the Post Anesthesia Care Unit (PACU), patients undergoing lesser procedures such as small oral excisions, neck dissections, thyroidectomy, etc. can be transferred to a surgical floor. Those undergoing more extensive resections requiring tracheotomy and major reconstruction need to be in a unit where they can be more closely observed for airway problems, flap viability, and hematoma formation. It may be preferable to keep these patients in the PACU overnight before transfer to a dedicated head and neck nursing unit. Prolonged Intensive Care Unit admission is not necessary. In patients in who prolonged enteral feeding will be required, percutaneous endoscopic gastrostomy (PEG) tubes can be inserted prior to surgery. Alternatively, nasogastric feeding tubes are inserted at the time of surgery and converted to PEGs in those few patients unable to resume oral intake prior to discharge. By the adherence to a detailed nursing care plan emphasizing early and intensive speech and swallowing therapy patients undergoing radical resections including those requiring free tissue transfer can usually be discharged in 12 days or less. Patients undergoing lesser procedures including peroral resections and neck dissections are generally discharged in one or two days.