Types of mouth cancer operations
This page is about the different types of operation used for mouth or oropharyngeal cancer.
Surgery to remove the cancer
Many of the operations to remove cancer of the mouth and oropharynx are major surgery. Some will cause changes to the way you look, eat, speak and cope with life. The ‘living with mouth and oropharyngeal cancer’ section of CancerHelp UK has information about how to cope with any changes that surgery can bring.
Depending on where your cancer is, surgery to remove the cancer can include removing all or part of your jawbone, your tongue or larynx (voice box), or all or part of the bones in the roof of your mouth. Or you might need to have layers of your lips removed.
Removing lymph nodes in your neck
Your surgeon may suggest removing the lymph nodes nearest your cancer. This might be a big operation. If your cancer has already spread to lymph nodes in your neck, then your surgeon is likely to remove all the nodes on one or both sides of your neck. This is called a neck dissection. It can have long term side effects.
Other operations
Some people may need other operations, such as tracheostomy (having an opening made in the front of your neck to allow you to breathe more easily), removal of teeth and placement of dental implants, or placement of a gastrostomy tube (a tube into your stomach to give you liquid food if you cannot swallow).
This page covers surgery for both mouth and oropharyngeal cancer but we sometimes just say mouth cancer in the text.
The amount of surgery you need depends on the stage of your cancer. The tests you have beforehand will help your specialist decide if surgery is an option for you. But your doctor may not be able to tell you exactly what stage your cancer is until after surgery.
There are a number of different operations to remove cancer of the mouth and oropharynx. Many of these operations are major surgery. You will have a general anaesthetic for them all. So you will be asleep for the whole operation. How much tissue the surgeon takes away will depend on where the cancer is. For example, if a large part of your tongue is involved then you may need to have a lot of your tongue removed (glossectomy).
Some of these operations will cause changes to the way you look, eat, speak and cope with life. We only describe the actual types of operations in this section. Our section about living with mouth and oropharyngeal cancer has information about how to cope with any changes that surgery can bring.
There is information below about operations for
- Removing the tumour and surrounding tissue
- Removing part or all of your jaw bone (mandible)
- Removing part or all of the bones in the roof of your mouth
- Removing layers of your lip (Mohs’ surgery)
- Removing part or all of your tongue (glossectomy)
- Removing part or all of your larynx
Removing the tumour and surrounding tissue
This is also called primary tumour resection. The surgeon removes all of the cancer with a section of normal tissue surrounding it. Surgeons call this border of healthy tissue a ‘clear margin’. It makes a boundary between the cancer and the tissue left behind and so helps to make sure that all the cancer has gone. To make sure, the surgeon will send all the tissue to the laboratory, where it is very closely examined to make sure there are no cancer cells in the border.
If your tumour is small and easy for your surgeon to reach, the surgery will be done through your mouth. But if it is a larger tumour or involves the oropharynx (throat), your surgeon will either make a cut through your neck or into your jawbone (known as a mandibulotomy) to reach the tumour.
Removing part or all of your jawbone (mandible)
If there is a chance that the cancer has spread to your jawbone, your doctor will suggest a mandibular resection. This is an operation to remove some or all of the tissue and bone in your jaw as well as the tumour. You may have a
- Partial thickness resection or
- Full thickness resection
A partial thickness resection means removing the thin layer of bone of the mandible that contains the teeth. You might have this done if your doctor thinks the cancer could have spread to your jawbone even though there is no sign of this on an X-ray. Your doctor may suspect this if it is hard to move the tumour from side to side when feeling inside your mouth.
A full thickness mandibular resection means removing all of the bone in your jaw. You may have this if an X-ray shows signs that the cancer has spread into the jawbone.
Removing part or all of the bones in the roof of your mouth
If you have a tumour affecting the bones in the roof of your mouth (hard palate) you will need to have one or more of these removed (maxillectomy). There are two possible operations
- A partial maxillectomy or
- A full maxillectomy
Both these operations will leave a space in the roof of your mouth into the nose above. A prosthodontist can make a false part (a prosthesis) to fill this space and make a new seal between the nose and the mouth.
Removing layers of your lip (Mohs’ surgery)
Mohs’ surgery is also called micrographic surgery. It is an advanced treatment procedure for skin cancer. If the cancer is in your lip, this type of surgery is very effective. The Mohs’ method involves removing the cancer in very thin slices. Your doctor will examine each slice under a microscope for cancer cells before taking another slice. They stop slicing thin layers when they find a slice free of cancer cells.
Moh's surgery is very useful in this situation because the amount of tissue removed may make a great deal of difference to your appearance. Examining every slice means that the doctor can remove the absolute minimum possible amount of tissue.
Removing part or all of your tongue (glossectomy)
Partial glossectomy means removing part of the tongue and total glossectomy means removing all of your tongue. These operations sound frightening and you will probably feel quite shocked if you are told that you need a glossectomy. But it is only ever done if it is absolutely necessary to remove your cancer. Most doctors will try radiotherapy or chemotherapy or both instead, if these can cure your cancer. This is because surgery to the tongue can make a lot of difference to your speech, may cause changes in eating and drinking and can change your appearance.
A partial glossectomy means removing less than half your tongue. You may still have speech changes after this operation. If you need a total glossectomy, (more than half your tongue removed) you will need to have your tongue rebuilt (reconstructed). Speech and swallowing will be more difficult, so a prosthodontist will make you a false part (prosthesis) to help with swallowing. People who have a total glossectomy need a lot of support and help to cope afterwards. There is information about changes in your speech and coping with mouth and oropharyngeal cancer in the section about living with mouth and oropharyngeal cancer.
Removing part or all of your larynx
Sometimes large tumours of the tongue or oropharynx mean that your surgeon needs to remove tissue that helps you swallow. A possible complication would be that food could then get into your windpipe (trachea) and lungs. This would be very dangerous as it could lead to choking and pneumonia. If this is going to be a risk, your surgeon may also remove all or part of your voicebox (larynx) along with the tumour in your mouth or throat. This operation is called a laryngectomy.
Your larynx is the connection between your mouth and your lungs which allows you to breathe. If you have the larynx removed, the surgeon attaches the end of your windpipe to a hole in your neck, which you then breathe through. The opening in your neck is called a stoma or tracheostomy.
A tracheostomy is a rare operation for cancer of the mouth and oropharynx. There is information about having a breathing stoma in the CancerHelp UK section about living with mouth and oropharyngeal cancer. There is also detailed information about partial laryngectomy and total laryngectomy in the cancer of the larynx section of CancerHelp UK.
If you have a large area of skin removed during your operation, you will need to have the area repaired. This can be done with
Skin flaps
A skin flap is a very good way of repairing a wound. It is more commonly used for repairing large or deep wounds. The surgeon frees a piece of muscle close to the wound, but doesn't remove it completely. Then the surgeon rotates the muscle, with or without its covering of skin, and stitches it over your wound to replace the tissue that has been taken away.
The surgeon will cut deeper than for a skin graft but they do not completely remove the skin. It is left partly connected and survives because it has its own blood supply. The donor site will be stitched closed.
Advances in surgery now allow surgeons to sew together small blood vessels under a microscope (micro vascular surgery). It gives surgeons many more options for reconstructing the mouth and oropharynx. They can now take tissue from other parts of the body for flaps and grafts, including from the bowel, muscles in the arms and tummy, or bones in the lower leg. All these can replace sections of the mouth, throat or jawbone removed during head or neck cancer surgery. If you are having major head and neck surgery, you will need to talk over all the options in detail with your surgeon.
Micro vascular surgery is very specialist surgery and is more complicated than a skin graft. The advantage is that this type of repair often looks better than a skin graft. It tends to be used where the appearance after surgery is very important - for example, on the face. A specially trained maxillofacial surgeon does this type of surgery.
Skin grafting
A skin graft means replacing an area of skin with another piece taken from elsewhere in the body. This is now used less often than it used to be. The surgeon will remove a thin sheet of skin from the ‘donor site’ and place it over the area that needs to be covered. The donor site is usually somewhere not too obvious, such as your inner thigh. After the operation the donor site looks like a large graze. The skin will grow back quite quickly over the next couple of weeks. Sometimes a thicker section of skin for the graft is cut out, and the donor site repaired by stitching it back together.
While the skin graft is healing it is very delicate. You must be very careful not to knock it. And your doctor and nurses will be very careful that your wound does not become infected. They may prescribe you a course of antibiotics to help prevent infection.
A disadvantage of skin grafting is that the new skin often looks different from the surrounding area. It may be a different colour and slightly depressed below the surface of the skin around it. This can affect your feelings about how you look, and may be difficult to cope with. There is information about changes in your appearance in the section about living with mouth and oropharyngeal cancer.
After skin grafting and flap repair, your nurses and doctors will keep a close eye on your grafted site to make sure the flap is getting a good supply of blood, to bring oxygen and nutrients to the healing tissues.
Cancers of the mouth and oropharynx often spread to the lymph nodes in the neck. If there is a risk that the cancer has spread to the lymph nodes in your neck, your surgeon may suggest surgery to remove the lymph nodes closest to the cancer. Even if the cancer can’t be seen in the lymph nodes, there could be a few cancer cells that will keep on growing if they are not removed. So the surgeon removes some of the lymph glands closest to the cancer and sends them to the laboratory to check them for cancer cells. If there is cancer in these nodes, you may need to have more of the nodes in your neck removed (neck dissection) or treated with radiotherapy. If you don't have the affected nodes removed or treated with radiotherapy, the cancer cells will continue to grow.
If the surgeon knows that there are cancer cells in the lymph nodes before your surgery they will remove some or all of the nodes in your neck during the operation to remove the cancer. This is called a neck dissection and is a big operation - it depends on exactly what is done.
Neck dissection surgery means removing all or some of the lymph glands in your neck. Surgeons don’t remove lymph glands routinely for everyone with mouth cancer because a neck dissection can have long term side effects. They have to consider carefully which patients might benefit from it. The different types of neck dissection include
Partial or selective neck dissection
If you have a partial or selective neck dissection, you only have a few lymph nodes in the area removed.
Modified radical neck dissection
There are different types of modified radical neck dissection. Your surgeon may just remove most of the lymph nodes between your jawbone and collarbone on one side of your neck. Or they may also remove one or more of the following structures
- A muscle at the side of your neck called the sternocleidomastoid muscle
- A nerve called the accessory nerve
- A vein called the internal jugular vein
Radical neck dissection
If you have a radical neck dissection, your surgeon will remove nearly all of the nodes on one side of your neck, as well as all of the sternocleidomastoid muscle and nerve tissue, and the internal jugular vein.
Sometimes a neck dissection operation is needed to give the best chance of stopping the cancer from spreading or coming back. But there can be side effects. These will depend on which structures in the area have been damaged or removed during the surgery.
The accessory nerve controls shoulder movement, so if it is removed, your shoulder will be stiffer and more difficult to move. If you have a partial or modified neck dissection, the weakness in your arm usually lasts only a few months. But if you have your accessory nerve removed during a radical neck dissection, the damage is permanent. Your doctor will refer you to a physiotherapist, who will show you some exercises to help improve the movement in your neck and shoulder. It is important that you do these exercises regularly.
If you still have problems with pain and movement a year after surgery, despite doing your exercises, your doctor may look into whether a further operation to reconstruct some of the muscles might help. But this will not be suitable for everyone.
Removing all of your sternocleidomastoid muscle will make your neck look thinner and sunken on that side.
Other common side effects of any neck dissection are caused by damage to some of the nerves that go to the head and neck area. They include
- Numbness in the ear on the same side as the operation
- Loss of movement in the lower lip
- Loss of movement on one side of the tongue
- Loss of feeling on one side of the tongue
Your doctor may suggest surgery to relieve symptoms even if your cancer can't be cured. This can give you a better quality of life for longer. You are most likely to need this type of treatment if your cancer is blocking any part of your throat and making it difficult for you to breathe and swallow. Your doctor may suggest a
Tracheostomy
If the cancer is blocking your throat and it is too big to completely remove, your surgeon may need to do an operation called a tracheostomy. This means having an opening made in the front of your neck to bypass the tumour and allow you to breathe more easily. The hole in your neck is called a stoma. If your surgeon expects you to have a lot of swelling in your mouth and throat after your surgery, you may have a temporary tracheostomy to help you breathe until the swelling goes down.
Removing teeth and putting in dental implants
You may need to have some or all of your teeth removed before your surgery or radiotherapy treatment. You may also need to have dental implants put in during or after your surgery. Your restorative dentist will talk this through with you before your operation. They will be happy to answer your questions, and they will be aware that you may be very worried and upset about having your teeth removed. So don’t be afraid to find out all you need to. You will find things easier to cope with if you understand exactly what is going to happen.
Gastrostomy tube
A gastrostomy tube is also called a PEG tube. PEG stands for percutaneous endoscopic gastrostomy. It means having a tube inserted into your stomach or small intestine through an opening made in your abdomen (a stoma). This can be a good, long term, solution if you can't eat because of problems with swallowing. For as long as you need to, you can have liquid feeds through the tube and directly into your stomach.
You can usually have the tube put in as an outpatient. This procedure is called an endoscopy. You swallow a long flexible tube into your stomach. This sounds very scary and your doctor will give you medicines to make you sleepy. Many people say that they cannot remember what happened afterwards. Or your doctor can put the tube in during surgery, through a small cut in your abdomen.
If you are worried about having an endoscopy while you are awake, do talk to your doctor about it. It may be possible to have a short anaesthetic if it would make you feel more comfortable.
If your swallowing problems are only temporary you can have another type of tube called a nasogastric tube. The tube goes down your nose and throat and into your stomach. Once you can swallow more easily, your nurse will take it out. You can have all or some of the nutrition you need through these tubes as liquid meals.
There is detailed information about tube feeding in CancerHelp UK’s section about diet problems and cancer.
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