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Pharyngectomy

A pharyngectomy is the removal of part of the pharynx. It is a general term that could vary from a small surgery that removed a tiny tumor on the back wall of the oropharynx to a major resection requiring a free flap for reconstruction.

In many cases, a pharyngectomy is done as part of removal of another tumor that extends into the pharynx. For example, a total laryngopharyngectomy is the removal of the entire larynx as well as the entire hypopharynx (along with variable parts of the oropharynx). Even a total laryngectomy often includes removal of a strip of pharynx, which is technically called a total laryngectomy with a partial pharyngectomy.

In general, a pharyngectomy is done for select cases of cancer of the nasopharynx, oropharynx or hypopharynx. Many cancer teams will recommend treatment of these types of tumors with chemotherapy and radiation, while others will recommend surgery followed by radiation. There are many factors to consider in making a treatment choice.

If your cancer returned or was never completely gone after being treated with chemotherapy and radiation for a pharyngeal cancer, surgery may be your only available option. This is called salvage surgery. Salvage surgery can be bigger and more difficult than if surgery was done up front. If salvage surgery is an option, it is imperative that your surgeon is able to obtain clear margins (no tumors along the edges of the resection, which means all the tumor is removed) for the benefits to outweigh the risks. Also, after performing a major resection after prior treatment (i.e., salvage surgery), it is important for fresh healthy tissue from another part of the body to be used to reconstruct the area. This will increase the chances of good wound healing and decrease the chances of major wound-related complications.

You should have an in-depth discussion with your entire cancer team about different options for treating your pharynx cancer.

Preparing for surgery

Your doctor and care team will let you know what you need to do to prepare for surgery. In general, you should not eat or drink anything (except essential medications) anytime after midnight prior to surgery. You should inform your doctor if you have a fever, productive cough or any other signs of infection. Your doctor will give you a medical clearance evaluation and give recommendations to optimize all the other organs in your body prior to undergoing general anesthesia and surgery.

On the day of surgery, you will need to arrive at the hospital or surgery center a few hours before the scheduled operation. This allows the nurses and anesthesiologist to confirm everything is in order for you to have as safe a surgery as possible. You will see your surgeon one last time before receiving the anesthesia and falling asleep, and you can ask any last-minute questions at that time.

What to expect

The type and extent of pharyngectomy will depend on a number of factors. A general overview of different types of pharyngectomies is as follows:

  • Nasopharyngectomy: This is only rarely performed in the U.S., and when it is, it is for recurrent nasopharynx cancer following failure of chemotherapy and radiation. Some surgeons have described doing this endoscopically through the nose, and some even using a robot. The standard open nasopharyngectomy requires a maxillotomy with a maxillary swing. In this procedure, the maxilla bone is cut down the midline with a saw and swung to the side to expose the nasal cavity and nasopharynx behind it. After the nasopharynx is resected, the maxilla is swung back into place, and a fixation plate and screws are used to secure the cut pieces of the maxilla together.
  • Total laryngopharyngectomy: See Total Laryngopharyngectomy
  • Total laryngectomy with partial pharyngectomy: See Total Laryngectomy. In this procedure, the larynx is removed, along with a part of the pharynx immediately next to it. If a significant portion of the pharynx is removed, the patient will probably require a flap to reconstruct the pharynx.
  • Partial hypopharyngectomy: This is partial removal of the hypopharynx. This can be done transorally with use of laryngoscopes and a laser (TLM) or with use of the surgical robot (TORS).
  • Posterior partial oropharyngectomy: When a tumor is isolated to just the posterior wall of the oropharynx, it might be possible to remove the tumor with a rim of normal oropharynx wall. It is important that the tumor not be stuck down to the fascia over the spine to achieve a successful operation. This can be done transorally either with direct visualization, with the surgical robot or with laryngoscopes and use of the surgical laser.

Recovery and aftercare

The recovery course will depend on the extent of the surgery and reconstruction. With some surgeries, you could go home after a few hours of observation in the recovery room; others might require staying in the hospital for one to two weeks. A stay longer than two weeks is usually due to some sort of post-operative complication that your doctors are working to improve.

If you do stay in the hospital for recovery, the recovery course can happen in a few different parts of the hospital. Your pathway might include trips to the recovery room, intensive care unit, step-down unit and a shared or private “floor” bed. As soon as possible and when the time is right for each step, you will progress from having your tubes and drains removed to being disconnected from the lines, and eventually getting up and out of bed. Asking for assistance to get out of bed to move around will help your recovery.

Once your doctors determine that you no longer need in-patient level care, you will be ready for discharge. The discharge planning process begins well before you are ready to leave the hospital. While some patients can go home from the hospital (with or without visiting nurses or home care), others might go to a rehabilitation or skilled nursing facility for a short while before going home. Your discharge planning team, which includes your doctors, social workers, nurses and physical therapists, along with you and your family, will determine the best place for you to go once you’re ready to leave the hospital.

Any additional reconstruction, cosmetic procedures or treatments are planned after discharge. This gives you time to recover from the initial surgery, get the pathology results of the surgery and make appropriate arrangements for the next steps.

Risks

As with any procedure, there are risks in undergoing a pharyngectomy that you need to be aware of. The exact risk will vary depending on the extent and type of pharyngectomy you undergo:

  • Bleeding, including hematoma: If there is severe bleeding after the procedure, your surgeon might need to quickly take you back to the operating room to stop the bleeding.
  • Seroma: This is a collection of normal body fluid in the neck after removal of the drain. This can be treated with observation, as the body will eventually resorb it, or repeated needle aspirations. The risk of leaving seroma is that it could become infected.
  • Infection: A pharyngectomy can be done with lymph node dissections on one or both sides of the neck, therefore, in theory, joining saliva and mucous with the sterile neck contents. Interestingly, infections of the neck are quite rare. Still, as with any surgical procedure, there is always risk of an infection after the surgery. This might require antibiotics and/or drainage of the infection.
  • Salivary fistula: This means that saliva is leaking from the pharynx into the neck. The chances of this increase if you have had previous treatment, including radiation and/or chemotherapy. This is because wound healing might be impaired in these cases. Typical treatment for this is to place a drain to divert the saliva away from critical structures in the neck and later to place packing into that diverted tract and let the body heal it up on its own. In some cases, an additional surgical procedure might be required to close the leak (such as a pectoralis major muscle flap).
  • Blood clots: Patients who undergo major surgeries, especially patients who have cancer, are at an increased risk of developing blood clots in their legs (deep venous thrombosis). Sometimes these blood clots can travel through the veins and into the lungs, causing a pulmonary embolus. This can be a serious complication, causing problems with oxygenation of your blood. If such a problem occurs, you will likely require anticoagulation (blood-thinning medication) to prevent more clots from forming and ending up in your lungs. This blood-thinning medicine, though necessary to prevent more clots, might itself cause another complication, such as bleeding, especially in the time immediately after surgery. This is why it is important for you to get out of bed early and move your legs. If you are not up and moving about, dynamic compression stockings should be used (these are like massage boots for your calves to keep the blood flowing). Also, you will probably be given a low dose of blood-thinning medication immediately after surgery to help prevent clots.

See Risks of Neck Dissection if you are having a neck dissection done at the same time as this procedure.