Surgical Procedures

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Neck Dissection

What is a neck dissection?

Neck dissection is an operation done to remove groups of lymph nodes from the neck. It can be done on one or both sides of the neck. Lymph node groups in the neck are numbered I-V. Selective neck dissection is removal of only a few of the groups of lymph nodes on one side of the neck. Comprehensive neck dissection involves removal of all lymph node groups on one side of the neck (levels I, II, III, IV, and V).

What is a radical neck dissection?

"Radical Neck Dissection" is an operation in which the sternocleidomastoid muscle, the internal jugular vein, and the spinal accessory nerve are removed in addition to removing all of the lymph nodes in levels I-V. This operation is still sometimes performed to remove very extensive neck disease. Modified Radical Neck Dissection is performed more frequently. This operation entails removing all of the lymph node levels but sparing at least one of the 3 structures mentioned above: the muscle, the jugular vein, and/or the accessory nerve. The type of operation you have depends on the type of tumor, the location and size of the tumor, and on whether or not there is already evidence of tumor spread to the lymph nodes.

Why do I need to have a neck dissection?

A neck dissection is done for 3 basic reasons: 1) therapeutic, 2) preventive, 3) access .

  • Therapeutic reasons: in some instances, a neck dissection is done to remove lymph nodes known or suspected to contain cancer that has spread from other locations (e.g., skin, mouth, nose, throat, etc.)
  • Preventive reasons: at times, even though there is no known spread of cancer to the lymph nodes, the chances are high that those lymph node contain cancer cells. In such instances, a neck dissection is done to properly stage the cancer and to determine whether further therapy (e.g., radiation) might be indicated. The lymph nodes are removed to determine whether or not the cancer has spread outside of its site of origin.
  • Access reasons: the lymph nodes in the neck are contained amidst fatty tissue. There are times when the fatty tissue and lymph nodes are removed to better delineate the anatomical structures of the neck for the purpose of accessing vessels or nerves. In some cases, in order to reach certain tumors, a neck dissection is done so that these difficult to access areas can be approached in a safe manner.

What do the lymph nodes do and won't I miss them?

Lymph nodes filter the lymph system, which is fluid that leaks out of blood vessels. They can trap bacteria and cancer cells. However, there are thousands of lymph nodes throughout the body. Removal of all the groups of neck lymph nodes involved in a neck dissection will not impair your ability to fight infection. On the other hand, there are times when people experience more swelling in the affected body areas where the lymph nodes were removed (this is what is called lymphedema).

What is lymphedema?

Lymphedema is swelling that occurs in a body area drained by a group of lymph nodes that was surgically removed. Examples include women whose arms swell following removal of axillary lymph nodes for treatment of breast cancer. Lymphedema is not as common in the neck and face. However, it is more likely to occur in the following groups of patients: 1) persons who have undergone neck dissection on both sides of the neck, 2) those who have had additional surgery such as removal of some part of their pharynx/throat or larynx/voice box, 3) those who have had removal of both internal jugular veins, and 4) those who have received radiation therapy.

Can lymphedema be treated?

Yes. Therapy usually involves meeting with a physical therapist who specializes in lymphedema therapy and following a prescribed course of therapy. In addition, elevating the head of the bed can prevent some of the swelling that usually occurs following surgery.

How much pain will I have after surgery?

There is usually very little pain or discomfort following neck dissection. Most individuals find adequate relief with occasional Tylenol.

What pain relievers should I use?

You can use Tylenol (up to 2 extra strength Tylenol or acetaminophen every 6 hours). In addition, you can use whatever medication your doctor prescribed for you. Do not use the prescribed medication in addition to Tylenol without checking with your doctor. Many prescribed pain medications also contain Tylenol (e.g., Darvocet, Tylox, Percocet, etc.) and it is possible to overdose if you take these in addition to Tylenol. You should not use any pain reliever other than Tylenol or the medication prescribed without first consulting your doctor. In general, aspirin, ibuprofen and many other over the counter or prescription anti-inflammatory medications prescribed for pain or arthritis can cause bleeding and should not be taken for at least 2 weeks after surgery.

What can I expect after surgery?

Surgery is done under general anesthesia in the operating room. You will wake up in the recovery room (also called the post-anesthesia care area, or PACU) and after a period of 1-2 hours will be transferred to your room. Sore throat is not uncommon for a few days after surgery (usually the result of the endotracheal breathing tube used during surgery). Drainage tubes are usually left in place after surgery and they will be removed 2-5 days after surgery.

Numbness (i.e., lack of sensation or feeling) on the operated side of the neck is common. The area of numbness may shrink in size over time (3-6 months) but some numbness will always be present.

What are potential complications of this surgery?

Serious complications are rare. They can include any or all of the following:

  • Bleeding and/or hematoma: bleeding may occur after surgery and require return to the operating room. In severe cases airway obstruction can occur.
  • Infection and/or fistula: if infection occurs one can develop redness, pain, or drainage at the surgical site. In more serious cases, the wound can break down and require dressing changes for several weeks until healing is complete. Fistula can occur, particularly in cases where surgery was also performed on or around the larynx, mouth or pharynx. A fistula is an abnormal communication between the mouth, nose or throat and the skin. If this occurs, dressing changes will be required over several weeks until the fistula closes. Further surgical intervention can sometimes be required.
  • Airway obstruction: bleeding or simply swelling of the tissues around the throat can make it difficult to breathe. In such cases, intubation with a breathing tube or an emergency tracheotomy may be required. If a person's airway becomes obstructed and an airway cannot be promptly established, hypoxia with severe brain damage or even death can occur.
  • Nerve injury: many motor nerves are dissected and potentially at risk for injury during a neck dissection. The facial nerve can be injured, especially the marginal mandibular division, which would result in weakness or asymmetry in the lower corner of the mouth. Injury to the hypoglossal nerve would result in tongue paralysis and difficulty chewing and swallowing. If the vagus nerve is injured, one can have problems with hoarseness and severe swallowing difficulties including aspiration. The spinal accessory nerve helps with arm/shoulder elevation and injury to this nerve can make it difficult to elevate the arm above one's head. The phrenic nerve helps elevate the diaphragm for breathing. Injury to one phrenic nerve would paralyze one side of the diaphragm and make it harder to breathe and cough.
  • Stroke: plaque from the carotid artery can be released during surgery around this artery. This rare complication can lead to stroke or even death. Patients with narrowing of the carotid arteries can also suffer stroke simply from having a slight reduction in blood pressure as a result of general anesthesia. Fortunately, this is also not a common complication.
  • Blindness: loss of sight has been reported following neck dissection. This is a very rare complication but the risk is significant if both internal jugular veins are removed at the same time or if one is removed and the other happens to become occluded with clot after surgery.
  • Heart attack : although not a direct complication of the surgery, myocardial infarction (or heart attack) can also occur especially in individuals with known risk factors for heart disease. Risk factors for heart disease are, among others, older age, smoking, high blood pressure, diabetes, and family history of heart disease or stroke.

Parotid Surgery

What is parotidectomy?

Parotidectomy is the surgical removal of the parotid gland.

What is a superficial parotidectomy?

Superficial, or lateral, parotidectomy refers to the removal of the portion of the gland which is to the side of the facial nerve. Total parotidectomy is the removal of the entire parotid gland, including that portion which is deep to the facial nerve.

Why do I need to have a parotidectomy?

Parotidectomy is done for the following reasons:

  • To remove tumors (benign or malignant) of the parotid gland.
  • To remove lymph nodes within the parotid gland that could contain cancer cells from elsewhere.
  • To prevent recurrent infection or blockage of the parotid gland.

What does the parotid gland do and won't I miss it?

The parotid gland produces saliva (it's commonly called a "spit gland"). There are a total of 6 major saliva glands (3 on each side); therefore, loss of one or two glands does not usually result in any noticeable decrease in saliva production.

What is Frey's syndrome?

Gustatory sweating, or Frey's syndrome, refers to increased facial sweating during eating. Some degree of gustatory sweating is quite common after parotid surgery. It occurs because the nerves that normally go to the parotid gland to produce saliva during eating become confused by the loss of their target and go on to innervate the sweat glands of the face. Then, as the person eats, the signal to produce saliva is delivered to the sweat glands since the parotid is missing.

Can Frey's syndrome be treated?

Yes. Many people have very mild forms of this gustatory sweating and they are either unaware of it or simply not bothered by the phenomenon. For those who are bothered by this, Botulinum toxin (Botox) can be injected into the skin to reduce or eliminate the sweating. Some people prefer to use anti-perspirant cream rubbed on their face prior to eating a meal - this reduces the amount of facial sweating they experience during a meal.

How much pain will I have after surgery?

There is usually very little pain or discomfort following parotidectomy. Most individuals find adequate relief with occasional Tylenol.

What pain relievers should I use?

You can use Tylenol (up to 2 extra strength Tylenol or acetaminophen every 6 hours). In addition, you can use whatever medication your doctor prescribed for you. Do not use the prescribed medication in addition to Tylenol without checking with your doctor. Many prescribed pain medications also contain Tylenol (e.g., Darvocet, Tylox, Percocet, etc.) and it is possible to overdose if you take these in addition to Tylenol. You should not use any pain reliever other than Tylenol or the medication prescribed without first consulting your doctor. In general, aspirin, ibuprofen and many other over the counter or prescription anti-inflammatory medications prescribed for pain or arthritis can cause bleeding and should not be taken for at least 2 weeks after surgery.

What can I expect after surgery?

Surgery is done under general anesthesia in the operating room. You will wake up in the recovery room (also called the post-anesthesia care area, or PACU) and after a period of recovery you may go home. Sore throat is not uncommon for a few days after surgery (usually the result of the endotracheal breathing tube used during surgery). A drainage tubes may be left in place after surgery and if so it will be removed 1-3 days after surgery. A bandage dressing may be applied to hold pressure on the side of your face in order to prevent bleeding under the skin. If present, this bandage should be kept on for 24-48 hours and removed according to your doctor's instructions.

Numbness (i.e., lack of sensation or feeling) on the operated side of the face is common. The area of numbness may shrink in size over time (3-6 months) but some numbness will always be present. In general, the earlobe will remain numb permanently but the sensation on the remainder of the ear and face should return gradually over a period of 6 months.

Will my face be numb?

Numbness, or the lack of feeling, affects parts of the face, neck and ear of all persons who have undergone parotidectomy. Numbness should be distinguished from weakness, which is the inability to move a certain part of the body (in this case, the face). The area of numbness initially affects the ear, the face and the upper neck. However, over a period of 6 months, the area of numbness will gradually shrink in size. For most people, the earlobe (but little else) remains numb forever.

What about facial weakness?

The most feared complication of parotid surgery is facial nerve injury which, in the worst case, would result in complete facial paralysis and facial droop. Fortunately, this is very rare. However, some degree of temporary facial weakness is not uncommon after parotid surgery. The degree of weakness depends on the extent of facial nerve manipulation which itself depends on the size of the tumor and its location relative to the facial nerve.

If the facial nerve or one of its divisions is cut during surgery, the surgeon will try to sew it back together using very fine suture material. If a portion of the nerve has to be removed, a cable graft (using a donor nerve) can be performed to bridge the gap between the two ends of the cut nerve. Any time that a nerve repair (or neurorrhaphy) is performed, recovery takes several months (6-12 months). In such cases, recovery may also be less than complete.

Most people who have a "superficial" parotidectomy will have no facial weakness after surgery. Some will have mild weakness of the lower corner of the mouth (during smile) and this will resolve by about 3 months after surgery.

Most people who have a total parotidectomy will have complete facial weakness for a period of 4-6 months. But even in these cases, a full recovery is usually the norm.

If you have some weakness after surgery, you can start to get recovery at about 6 weeks but in many cases it will take 6 months or more for recovery to be complete. Recovery is usually complete but may be less than complete for older individuals (over 65), those who smoke, diabetics, and those who have radiation exposure.

What is facial reanimation or rehabilitation?

Several procedures can be done to minimize the impact of facial paralysis. A drooping brow can be lifted. An eyelid that does not close (thereby exposing the eye to injury) can be tightened and adjusted in order to achieve full closure. Other procedures can also be done to improve the appearance of the lower face (e.g., mouth corner). In general, these procedures are indicated for those in whom spontaneous recovery of function is not expected. In some instances, they can also be done for individuals in whom recovery is expected but known to take several months.

What are potential complications of this surgery?

Serious complications are rare. They can include any, or all, of the following:

  • Bleeding and/or hematoma: bleeding may occur after surgery and require return to the operating room. In severe cases airway obstruction can occur.
  • Infection and/or fistula: redness, pain, or drainage at the surgical site are signs of infection. In more serious cases, the wound can break down and require dressing changes for several weeks until healing is complete. Fistula can occur, particularly in cases where surgery was also performed on or around the larynx, mouth or pharynx. A fistula is an abnormal communication between the mouth, nose or throat and the skin. If this occurs, dressing changes will be required over several weeks until the fistula closes. Further surgery may be required. The most common type of fistula to occur after parotid surgery is leakage of saliva through the incision (not to be confused with Frey's syndrome). If this type of (sialocutaneous) fistula occurs, it is usually treated with pressure dressings, medications, and/or Botox. Further surgery is rarely required.
  • Airway obstruction: bleeding or simply swelling of the tissues around the face, mouth, or throat can make it difficult to breathe. In such cases, assistance with breathing using a breathing tube or an emergency tracheotomy may be required. If a person's airway becomes obstructed and an airway cannot be promptly established, hypoxia with severe brain damage or even death can occur.
  • Nerve injury: facial nerve injury (see above) can occur and result in either temporary or permanent inability to move the face (e.g., smile, frown, wink, etc.). The sensory nerves in this area (great auricular nerve) are almost always cut in order to remove the gland. This results in the loss of feeling in the face and ear.
  • Stroke: plaque from the carotid artery can be released during surgery around this artery. This rare complication can lead to stroke or even death. Patients with narrowing of the carotid arteries can also suffer stroke simply from having a slight reduction in blood pressure as a result of general anesthesia. Fortunately, this is also not a common complication.
  • Heart attack: although not a direct complication of the surgery, myocardial infarction (or heart attack) can also occur especially in individuals with known risk factors for heart disease. Risk factors for heart disease are, among others, older age, smoking, high blood pressure, diabetes, and family history of heart disease or stroke.

 

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