Head & Neck Surgery


Most registries across India report incidences of 22 - 30 % forhead and neck cancers amongst total cancers in the Indian males. The main etiology in India appears to be the widespread use of tobacco products, the habit starting as early as 10years of age and affecting the lower socio economic strata in both rural and urban group/s. There is little doubt that prolonged use of tobacco leads to squamous cancers(HNSCC ) of upper aerodigestive tract beginning initially as precancers where the disease can be easily reversed by appropriate discontinuation of the habit and adoption of healthy lifestyle/s with ingestion of anti-oxidants and regular attention to orodental hygiene . The other emerging etiology by Human Papilloma Virus ( HPV ) which is perceived as an epidemic in the west is today seen in about a third with HNSCC in this country. This has a predilection amongst the younger group of individuals where their sexual promiscuity and altered sexual habits predispose them to the HPV which normally resides in the female genital tract and oncologic subtypes 16,and 18 have been unequivocally implicated as a causative agent in the cancers of the cervix .

HNSCC is the commonest cancer seen in the H&N region . Other malignant tumors include differentiated thyroid ( Papillary , follicular cancersand its different variants ), parotid and other salivary gland cancers ( mostly arising from glandular epithelium ), cancers of the the sinonasal tract ( HNSCC, salivary neoplasms , and neuroendocrine cancers , esthesioneuroblastomas and sarcomas ) and nasopharyngeal cancers ( mostly Undifferentiated carcinomas and occasionally SCC )

Head and neck is a cosmetically and functionally important zone ; hence management of tumors if this region is complicated and may adversely impact the important functions of sight, hearing , taste , olfaction , mastication , swallowing, breathing and speech . It is likely that functions of these organs may have been already compromised by tumors that affect them, especially in those advanced lesions which are strategically situated and have affected the function/s of the organs by their growth ; in the best interest of the afflicted individuals , these parameters need quantitative evaluation so that patients are realistically apprised pre-treatment of their disability and expected outcomesboth oncologic as well as functional . They should be counselledbefore onset of treatment that final outcome of function after cancer directed modalities maynot ever become as good as normal.

Prior to initiation of any treatment it is essential to optimize treatment for each cancer based on evidence based studies ( preferably ). This is facilitated by using the TNM staging system wherein the tumor is fully evaluated to assess its physical dimensions , its spread to regional lymph nodes as well as distant organs . The metastastic potential is determined both by the biology as well as to the resistance of the host . Once staging has been done, the patient with the tumor is discussed before a multidisciplinary tumor board comprising of H&N Surgical oncologist, radiation oncologist ,medical oncologists and rehabilitation experts . It is important that patient participate in the decision making based on their expectation and the available information about the tumor behavior and the general condition of the patient . Treatment may be defined as “ curative “ in their intent ; however in those individuals where tumor is too advanced or the general condition of the patient is so compromised by co morbid health conditions , only symptom and disease palliation may be initial plan . Generally tumor stage determines the goal of the treatment. If the patient is in good health and has little or no co- existing illness , early stage disease ( defined as stage 1 or 2 ) generally lend themselves to curative outcome/s with single modality treatment of either functional preserving surgery or radiation therapy in a reasonably high number of affected individuals with minimum permanent complications or sequelae . On the contrary , if the disease is in advanced stage 3or 4 , management is usually more complex and challenging owing to complexity of surgery ,or complications/ toxicities associated with the adjuvant modalities which are usually more than one and can be long drawn leading to increased hospital stay with its attendant adverse effect on the costs and morale of the patient . In such a scenario , supportive care by speech and swallowing experts , clinical psychologists and nutritional experts can ensure that the patients and their attendant/s do not feel isolated . Even in patients with advanced stage disease which has not spread to distant organs , if the patient is in robust health with minimum co morbidities and is deemed to have good performance status , they can benefit from high end surgery performed by an experienced team who usually combine their resection and reconstruction in one stage procedure and ensure a reasonably predictable hospital course . Should the histopathology of the tumor specimen reveal aggressive biologic portent then these patients will be offered adjuvant treatment to prevent recurrent disease usually in form of radiation therapy with /without chemotherapy . The commonest types of the HNSCC that benefit from such an approach are advanced stage cancers of oral cavity , hypopharynx, sinonasal cancers and larynx in that order .


Holistic management of HNSCC should start with identification and education of the masses at large by health awareness programs at level of secondary and high schools as well as at college levels. Some degree of community service visiting the cancer centers and hospices which house the terminally ill will be an early wake up call for the young minds and serves to indoctrinate them subtly about the evils associated with tobacco and alcohol use . Many health providers ( medical students and paramedics ) do not get exposed to H&N oncology cases during their undergraduate training . Others health professionals , do not choose oncology subjects as their vocation .In either situations, the knowledge they get as a professional is of very low standard- not enough to disseminate the dangers to the lay public .

The area of community and preventive oncology needs to be developed ; the 3 tenets of cancer prevention Viz primary , secondary and tertiary should be put into practice at all medical institutions . Focus should be placed on the primary and secondary preventions where efforts are directed at avoidance of exposure to known carcinogens ( in HNSCC Tobacco and alcohol ) and detection and downstaging of early stage cancers and precancers respectively. Both these objectives , if adopted seriously at community level will in the near future ( maybe a decade or so ) lead to a diminution in the incidence of this cancer . Not only will the invasive cancers incidence go down but lesions detected at precancer level can be reversed and early stage cancers can be “controlled “ without incurring overt cost or morbidity. The only scourge associated with long term tobacco and alcohol use is the “ field cancerization effect “ which affects large parts of the upper aerodigestive tract which are morphologically normal in appearance but may harbor molecular changes that herald the development of 2nd , 3rd primaries as the patient lives long and therefor mandates regular long term follow up by their treating oncologists . There is no better recommendation in prevention than the age old adage of “ prevention is better than cure “. Tertiary prevention strategies directed towards established invasive cancers are not only associated with less than satisfactory control rates but are associated with both acute morbidity and long term sequelae which mar the oncologic gains of cancer directed therapy and leave the patients physically, psychologically and economically drained .