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Oral Cavity Composite Resection
Depending on the location of the malignant tissue, Dr. Coniglio will provide information specific to your surgery. The following information applies to most patients requiring oral cavity surgery.
When treating oral cavity lesions, the first priority is to completely remove the tumor or malignancy. The second priority is to preserve function. When deciding the best course of treatment, it is important to note that the first attempt is the best chance at removing all the diseased tissue and cells. It is important to err to the side of being aggressive initially so that we are not left in the position of chasing the spread of malignant cells throughout the body.
Although no one wants to have head and neck cancer, it has the benefit of following a predictable pattern. Most head and neck cancer follows the pathway from the head to the neck to the chest. Also, head and neck cancer routinely stays on one side of the body (neck) when it travels. Therefore, along with surgically removing the tumor, we check the lymphatic channels (lymph nodes) in the neck (a procedure called a neck dissection) to stay one step ahead of any spread. Removing these lymph nodes also can aid in preventing the spread of disease and will determine if radiation therapy is necessary.
In order to promote healing, your body needs optimal nutrition following your head and neck surgery. Swallowing will be difficult initially because of the surgery and the swelling inside your mouth. We need to protect your ability to obtain nutrition by way of a temporary small, thin feeding tube in your nose or a feeding tube through your belly. If Dr. Coniglio recommends a tube through your belly (a PEG), you will have the tube inserted by a gastroenterologist at a separate outpatient procedure prior to the head and neck surgery. We will help coordinate this appointment for you. This tube is temporary and can be removed as soon as you can maintain adequate nutrition on your own.
The tongue is a very durable, strong muscle and can tolerate removal of a fair portion while still able to function adequately for swallowing and nutritional needs. Usually surgical treatment of oral cavity lesions involves opening the lower lip and jawbone (mandible) to excise (remove) the malignant tissue. This surgery may require the removal of one or more teeth. We will avoid that if at all possible. Reconstruction routinely involves a Plastic Surgeon who will obtain a flap or graft to repair the defect created by tissue removal. If a flap or graft repair is indicated, you will meet with a Plastic Surgeon prior to the surgery. They will describe to you how they will do the reconstruction and from where they will obtain the flap (forearm, thigh, leg, abdomen). They will reconstruct using a flap that has a neck artery and vein if possible. If a graft, they may use tissue from the arm because it is pliable. Using metal screws, Dr. Coniglio will then reconnect the two sides of the mandible and sew the lip back together.
A temporary side effect of the surgery is a fair amount of swelling inside your mouth. Therefore, we need to protect your airway (breathing) with a temporary tracheotomy. The tracheotomy tube is usually in for approximately one week and will be removed prior to your hospital discharge.
Immediately following your surgery you will be admitted to the intensive care unit for at least one to two nights where the nurses will monitor the flap. A Doppler unit, which is a special microphone, is employed to listen to be sure that there is good blood flow. If you have a flap from your arm, your arm will be elevated on a pillow. You will be given aspirin daily following the surgery to provide good blood flow to the flap. The dressing on your arm will be changed in the hospital approximately five or six days postoperatively.
As far as pain, you will have a morphine pump immediately postoperatively and you will be able to control the pain management yourself. In order to remove all of the cancer, it is not uncommon that nerves need to be cut. From that the good news is that there is not a lot of pain. However, there is numbness that can be temporary or permanent. We will not know the effects of this until approximately nine months to one year following the surgery, since restoration of nerve function is very slow.
We avoid blood transfusion if at all possible. Routinely, we are asked if family members can donate the blood. Any family members may be tested for this but most of the time they are not match or time constraints (need two weeks minimum to arrange for family member to donate if they are a match).
If radiation therapy is indicated, it will not be started until four to six weeks following surgery. Your body needs this time to have a chance to heal. If you have radiation therapy, the PEG stomach tube may stay in longer until after the radiation therapy is completed.
As with any surgical procedure certain risks must be discussed before obtaining surgical consent.
Bleeding
Some bleeding is expected with any surgery, however abnormal postoperative bleeding occurs in about 1% of cases. If it does occur, bleeding usually occurs within the immediate postoperative period. Hematoma, a collection of blood under a skin, is caused by a break in a blood vessel. Treatment consists of draining the collection of blood while in the hospital.
Infection
Infection is rare due to the excellent vascularity to the tissues. A prescription for preventative antibiotics is provided for use in the postoperative period. Clindamycin, an antibiotic, may be indicated for the mouth.
Fistula
A fistula is a leak from the oral cavity through the skin of the neck. This is usually a temporary condition and can be treated with rinsing and medication.
Numbness or Weakness
Every attempt will be made to prevent or minimize weakness or numbness. However, depending on the extent of tumor involvement, facial, neck or shoulder weakness or numbness can result. This temporary or permanent side effect is most commonly due to surgical swelling or stretching of the nerve. If surgical weakness persists following a neck dissection you will be given exercises to perform and possibly physical therapy. Due to the proximity of the facial nerve, facial weakness is a very rare complication.
Neuroma or Seroma
A neuroma, a bundle of nerve endings, can develop as a result of surgery. This would present as hypersensitivity in the surgical area. These take years to develop and can be removed if they persist. If a seroma, a collection of tissue fluid, develops, it can be drained in the office.
Bone Nonunion
A rare complication is non-healing of bone. This may require a secondary surgical procedure to promote healing.
Anesthesia
Complications from anesthesia are known to exist. These complications (anything from nausea to stroke or death) are quite uncommon since patients are usually young and healthy.
Pre-Operative Instructions
Nothing to eat or drink after midnight the evening prior to your surgery. This includes all foods, liquids, water, candy, mints or gum. You may brush your teeth the morning of surgery. Your procedure will be cancelled if you do not follow these instructions.
- Notify us of all routine medications and significant health history. Take medications as directed with just a sip of water.
- Please avoid aspirin, ibuprofen or any products containing these medications for one week prior to your surgery. If you are on any medications that affect bleeding, please notify the nurse at this time.
- Do not bring valuables (cash, credit cards, jewelry) to the hospital.
- Remove all make-up and nail polish prior to arriving at the Center.
- Please contact the hospital on the business day prior to your surgery to confirm your arrival time.
Post-Operative Expectations
Many times after extensive oral cavity surgery it is difficult to swallow. You may be temporarily dependent on a feeding tube, either nasal or through the stomach (PEG) for nutrition unless you have discussed otherwise with Dr. Coniglio. You will be encouraged to maintain good nutrition for optimal healing with Ensure®, Jevity® for tube feeding or an instant breakfast if taking calories by mouth. If one needs swallowing rehabilitation, a consultation with a speech and swallow therapist can be ordered. Dentures do not usually fit and one needs to wait to use them until swelling subsides.
Other postoperative expectations may include the following:
- Initially your speech will be affected but should improve over time. If a temporary tracheotomy is indicated, the site should heal quickly.
- Most commonly patients require postoperative radiation therapy. Our office will assist you in arranging a consultation at a convenient location. At this consultation a doctor who specializes in radiation oncology will address all questions regarding radiation therapy including indications, side effects, long-term effects and any scheduling of the actual therapy visits.
- Follow-up visits with our office will be scheduled every two months for up to two years following surgery. The office visits will continue to become less frequent after the two-year postoperative date.
- Although this surgery is perceived as overwhelming to the patient, most patients recover well, return to work and can lead active and productive lives.
Please Remember
Discharge planning begins on the day of hospital admission. As soon as you are admitted, your discharge needs are being assessed and addressed. For example, if you need services at home such as a community health nurse, these arrangements will all be made for you prior to your hospital discharge. This surgery requires a team effort and we are all here to provide for your safety and wellness.
After your hospital discharge, please notify the office for any of the following:
- Fever over 102° F
- Difficulty breathing or painful swallowing
- Swelling that increases rather than decreases with time
- Pain not managed by pain medication
For an emergency please call our professional answering service at 585-258-4840.
Please notify the office 585-256-3550 for any concerns. We are here to help in any way we can.
Dr. John U. Coniglio and Staff
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