GC187 Head And Neck Cancer Problems Function And Shape
Head and neck cancer can cause significant problems with essential functions such as swallowing, speech, breathing, and hearing, as well as disfigurement affecting facial appearance and body image, often resulting from both the disease itself and its treatment.
Head and Neck Cancer Problems: Function and Shape
This lecture by Dr. Velda Chow (Division of Head and Neck Surgery & Plastic and Reconstructive Surgery, HKU/QMH) addresses the unique surgical challenge of head and neck (H&N) cancer: you must cure the cancer (resection) while preserving or restoring both function and form (reconstruction). [1]
Why this lecture matters: The head and neck is the most anatomically dense region of the body — a small area packed with structures responsible for vision, breathing, eating, speaking, and appearance. Cancer surgery here inevitably disrupts some of these, so every operation is a careful balance between oncological radicality and functional/cosmetic preservation. This is the conceptual backbone you need for H&N cancer questions on the exam.
Learning Objectives:
- Understand the sub-regions of the H&N area and why cancer here poses special problems
- Know the five major functions at risk (Vision, Airway, Taste, Swallowing, Speech)
- Understand the principle of resection margins for different tumour types
- Know the "Ladder of Reconstruction" and the pros/cons of each rung
- Appreciate the concept of individualized reconstruction for optimal functional and cosmetic outcome
Core Concepts and Mechanisms
"Large numbers of important and vital organs concentrated in a small area" [1]
Think about it from first principles: the head and neck contains your eyes, brain, airway, swallowing apparatus, salivary glands, voice box, cranial nerves, major blood vessels (carotids, jugulars), skull base — all within an area roughly the size of a football. Any tumour growing here — or any surgery to remove it — threatens multiple vital structures simultaneously.
"Most frequently exposed region of the body" — "Anatomical disruption will affect morphology and physiology" [1]
Unlike abdominal or thoracic cancers where the surgical site is hidden, H&N cancer defects are visible. Patients have to live with disfigurement that affects their social interactions, self-image, and psychological health. This is why reconstruction is not an afterthought but an integral part of treatment planning.
"Systemic metastasis uncommon, reasonable life-expectancy" [1]
This is a crucial exam point. Most H&N SCCs spread locoregionally (locally + to cervical lymph nodes) rather than distantly. This means:
- Patients often survive for years even with advanced disease
- They have to live with the functional and cosmetic consequences of treatment
- This makes quality-of-life considerations paramount — you're not just prolonging survival, you're preserving how someone eats, breathes, talks, and looks
High Yield — Why Reconstruct?
Because H&N cancers rarely metastasize systemically and patients have reasonable life expectancy, the cosmetic and functional consequences of surgery are critical. This is why majority of H&N cancers require both RESECTION and RECONSTRUCTION. [1]
Sub-regions: Nasal cavity, Nasopharynx, Oropharynx, Oral cavity, Hypopharynx, Larynx–trachea, Para-nasal sinuses, Salivary glands, Skull base [1]
Each sub-region has a different predominant pathology, risk factor profile, and treatment approach:
| Sub-region | Common Cancer | Key Risk Factor | Primary Treatment |
|---|---|---|---|
| Oral cavity | SCC | Smoking, alcohol, betel nut | Surgery ± adjuvant RT/CRT |
| Oropharynx | SCC | HPV (increasing), smoking/alcohol | CRT (function-preserving) or surgery (TORS) [5] |
| Nasopharynx | Undifferentiated carcinoma (Type III) | EBV, Southern Chinese ethnicity | RT ± concurrent chemo [10] |
| Hypopharynx | SCC | Smoking, alcohol | CRT or surgery + reconstruction |
| Larynx | SCC | Smoking | Early: RT; Advanced: CRT or total laryngectomy |
| Paranasal sinuses | SCC, adenocarcinoma | Woodworking, nickel exposure | Surgery ± RT |
| Salivary glands | Mucoepidermoid, adenoid cystic | Previous radiation | Surgery ± RT |
| Skull base | Various (meningioma, SCC extension) | — | Surgery (craniofacial) ± RT |
Field cancerization (from Felix PY Lai [5]): The entire upper aerodigestive tract mucosa is chronically exposed to carcinogens (tobacco, alcohol), leading to widespread pre-malignant changes. This means:
- Synchronous tumour = second primary detected within 6 months
- Metachronous tumour = second primary detected > 6 months
- Panendoscopy (direct laryngoscopy + bronchoscopy + OGD) is recommended at initial evaluation to detect second primaries [5]
The Five Major Functions at Risk
Visual acuity – unilateral or bilateral; Dry eye – post-irradiation; Epiphora – lacrimal duct drainage system; Diplopia – extraocular muscle / periorbita; Dystopia – loss of orbital floor [1]
Why each matters:
| Problem | Mechanism | Clinical Scenario |
|---|---|---|
| Visual acuity loss | Direct tumour invasion of orbit/optic nerve, or surgical sacrifice | Sinonasal tumours, skull base tumours |
| Dry eye | Radiation damages lacrimal gland → decreased tear production | Post-RT for NPC or sinonasal tumours |
| Epiphora (excessive tearing) | Tumour or surgery disrupts nasolacrimal duct drainage | Maxillary/ethmoid sinus tumours |
| Diplopia (double vision) | Extraocular muscle infiltration or periorbital disruption | Orbital floor/medial wall tumours |
| Dystopia (eye malposition) | Loss of orbital floor support → globe sinks (enophthalmos) | Post-maxillectomy without orbital floor reconstruction |
Protection of the functioning eye during anaesthesia: Eye shield, Chloramphenicol ointment, Tarsorrhaphy, Knowing the anatomy [1]
This is a practical surgical point: during any H&N operation near the eye, you must protect the cornea. Tarsorrhaphy (suturing the eyelids together temporarily) prevents corneal exposure and desiccation. Chloramphenicol ointment provides lubrication and prophylaxis.
Temporary – swelling; Permanent – tumour / stricture [1]
ALWAYS Protect the Airway
For all H&N cancer, airway management is the first priority. Tumours of the oral cavity, oropharynx, hypopharynx, and larynx can cause airway obstruction. Post-operative swelling (especially after tongue/floor of mouth surgery) can worsen this. A planned tracheostomy may be needed pre-operatively. [5]
Temporary airway compromise: Post-operative oedema (e.g. after glossectomy, mandibulectomy) — usually managed with temporary tracheostomy or elective intubation for 24-48 hours.
Permanent airway compromise: Tumour causing irreversible obstruction, or post-treatment stricture (fibrosis from RT). Total laryngectomy creates a permanent tracheostome (the trachea is brought directly to the skin of the neck).
Temporary – post chemotherapy; Permanent – after irradiation / surgery [1]
Why: Taste buds are on the tongue (anterior 2/3: CN VII chorda tympani; posterior 1/3: CN IX) and palate. Chemotherapy causes temporary dysgeusia because it damages rapidly dividing taste bud cells (they regenerate in 2-3 weeks after chemo). Radiation destroys taste buds more permanently and also damages salivary glands (xerostomia worsens taste further). Surgical resection of the tongue obviously removes taste buds permanently.
Voluntary phase usually affected by tumors in the head and neck region; Usually immediately after glossectomy or pharyngectomy; Sometimes delayed presentation after radiotherapy [1]
Phases of swallowing refresher:
- Oral preparatory phase (voluntary): mastication, bolus formation — needs tongue, teeth, palate, buccal muscles
- Oral propulsive phase (voluntary): tongue pushes bolus posteriorly — needs functioning tongue
- Pharyngeal phase (involuntary/reflex): swallow reflex, epiglottic closure, pharyngeal constriction
- Oesophageal phase (involuntary): peristalsis
H&N tumours primarily affect the voluntary phases because they involve the oral cavity and oropharynx. After glossectomy, the tongue can't form or propel the bolus. After pharyngectomy, the pharyngeal conduit is disrupted.
Delayed dysphagia after RT: Radiation fibrosis develops over months to years, causing:
- Stricture of the pharynx/oesophagus
- Reduced pharyngeal motility
- Trismus (limited mouth opening from fibrosis of masticatory muscles)
- Xerostomia worsening bolus transit
Swallowing sites affected: Oral cavity, Oropharynx, Hypopharynx [1]
Phonation – post laryngectomy; Articulation – post glossectomy / nasal / paranasal sinus surgery [1]
Two components of speech:
- Phonation = sound generation. The larynx vibrates the vocal cords to produce sound. After total laryngectomy, there is NO larynx → no phonation possible via normal mechanism.
- Articulation = shaping sound into words. The tongue, lips, teeth, palate, and nasal cavity modulate sound. After glossectomy or palate resection, articulation is impaired even if phonation is intact.
Speech rehabilitation options: Esophageal speech, Pneumatic device, Electronic device, Speaking valves [1]
| Method | How It Works | Pros | Cons |
|---|---|---|---|
| Esophageal speech | Swallow air into oesophagus, belch it out to vibrate pharyngo-oesophageal segment | No device needed | Difficult to learn, low volume, breathy quality |
| Pneumatic device | External device placed over tracheal stoma, uses exhaled air to vibrate a membrane | Relatively easy to use | Requires one hand to hold device |
| Electronic device (electrolarynx) | Handheld vibrator placed against neck or cheek | Easy to learn, immediate use | Robotic/mechanical voice quality |
| Speaking valve (tracheo-esophageal puncture/TEP) | One-way valve between trachea and oesophagus; exhaled air vibrates oesophageal mucosa | Best voice quality among all options, hands-free | Requires surgical creation of fistula, maintenance of valve, risk of aspiration |
Breathing, mastication/swallowing, pain, bleeding, smelly, look [1]
This slide describes the "total suffering" of advanced H&N cancer — patients experience a constellation of problems that profoundly affect quality of life:
- Breathing: airway obstruction
- Mastication/swallowing: inability to eat normally → malnutrition, aspiration
- Pain: tumour invasion of nerves, bone
- Bleeding: tumour erosion into vessels (carotid blowout is a feared complication)
- Smelly: necrotic, infected tumour tissue (fungation)
- Look: visible disfigurement → social isolation, depression
This is why H&N cancer management requires a multidisciplinary team (MDT): surgeon, oncologist, radiation oncologist, speech therapist, dietitian, social worker, psychologist, prosthodontist.
Resection: oncologically clear, yet preserve important organ functions → margins of resection [1]
Reconstruction: choose the best option for individual patient [1]
Therefore:
Majority of head and neck cancers require both RESECTION and RECONSTRUCTION [1]
This is the central thesis of the lecture. The two go hand-in-hand and must be planned together from the outset. You cannot plan the resection without considering how you will reconstruct, and vice versa.
Facial BCC: 3–5 mm; SCC: 5–15 mm; Melanoma: 5–30 mm; Dermatofibrosarcoma protuberans (DFSP): 30–50 mm [1]
Exam High Yield — Resection Margins by Tumour Type
Know these numbers cold. They are frequently tested in MCQs and SAQs.
| Tumour Type | Margin (mm) | Rationale |
|---|---|---|
| BCC | 3–5 mm | Low-grade, slow-growing, rarely metastasizes; subclinical extension is limited |
| SCC | 5–15 mm | More aggressive than BCC, perineural/lymphovascular invasion possible; wider margin needed |
| Melanoma | 5–30 mm (depends on Breslow thickness) | Radial growth phase can extend far beyond visible lesion; margin increases with tumour thickness |
| DFSP | 30–50 mm | Locally aggressive with high recurrence rate; tentacle-like extensions into surrounding tissue |
Why do margins vary? The required margin depends on the biological behaviour of the tumour:
- Tumours with more aggressive local invasion (melanoma, DFSP) need wider margins
- Tumours with subclinical microscopic extensions need margins beyond what is grossly visible
- In the face, wider margins create larger defects that are harder to reconstruct, so there's always a trade-off between oncological safety and functional/cosmetic outcome
Melanoma margin by Breslow thickness (for reference):
- In situ: 5 mm
- ≤1 mm: 1 cm
- 1.01–2 mm: 1–2 cm
-
2 mm: 2 cm (up to 3 cm in some guidelines)
Mohs micrographic surgery is used for high-risk facial lesions (especially BCC, SCC near eyes/nose/lips) because it allows 100% margin assessment while preserving maximum tissue — the tumour is excised in layers, each layer is examined under the microscope before the next layer is taken, so you only remove what is necessary. [9]
Tools for Reconstruction: The Reconstructive Ladder
'Ladder of reconstruction' — From simple to difficult — Does not take into account the aesthetic and functional result of reconstruction [1]
The Reconstructive Ladder is a foundational concept in plastic surgery. It ranks reconstructive options from simplest to most complex:
| Rung | Technique | Description |
|---|---|---|
| 1 | Secondary intention | Let wound heal on its own (granulation) |
| 2 | Primary closure / direct closure | Direct suture of wound edges |
| 3 | Skin graft | Transfer of skin without its own blood supply |
| 4 | Local flap | Tissue moved from adjacent area with its own blood supply |
| 5 | Regional/Distant flap | Tissue brought from another body region (e.g. pectoralis major) |
| 6 | Microvascular free flap | Tissue transferred with vessels, re-anastomosed microsurgically |
What the ladder diagram shows: a vertical green arrow from simple (direct closure) up through skin graft → local flap → distant flap → complex (free flap). The slide’s own ladder starts at direct closure; secondary intention is the usual plastic-surgery rung below that and is included here for completeness. [1]
Important Nuance
The ladder is a teaching tool, not a rigid algorithm. The lecture explicitly states it "does not take into account the aesthetic and functional result of reconstruction." [1] In modern H&N surgery, you often "skip rungs" — going directly to a free flap when it gives the best functional/cosmetic outcome, even though it's technically more complex. The principle is to choose the best option for the individual patient, not necessarily the simplest. This concept is sometimes called the "reconstructive elevator."
Advantages: Simple, Thin and pliable, Minimal donor site morbidity [1]
Disadvantages: Need a well-vascularized bed, Poor tolerance to infection, Secondary contracture [1]
Key distinction: Graft vs. Flap:
Graft: need to develop its own blood supply from the recipient bed [1]
Flap: need to bring along its own blood supply from its blood vessels [1]
This is one of the most commonly tested concepts:
| Feature | Graft | Flap |
|---|---|---|
| Blood supply | Depends on recipient bed (takes 3-5 days to revascularize) | Brings its own blood supply |
| Bed requirement | Must be well-vascularized (not over bone, cartilage, tendon, or irradiated tissue) | Can be placed on any bed, including avascular ones |
| Thickness | Thin (split-thickness) or thicker (full-thickness) | Contains skin, subcutaneous tissue ± muscle ± bone |
| Tolerance to infection | Poor (no intrinsic blood supply initially) | Better (has its own blood supply) |
| Contracture | More (especially split-thickness grafts) | Less |
| Donor morbidity | Low | Variable (depends on flap type) |
| Complexity | Simple | Moderate to very complex |
Types of skin graft:
- Split-thickness skin graft (STSG): epidermis + partial dermis. More contracture, better take rate on suboptimal beds. Donor site heals by re-epithelialization.
- Full-thickness skin graft (FTSG): epidermis + full dermis. Less contracture, better cosmetic match, but requires a well-vascularized bed and primary closure of donor site.
Advantages: Simple, Good color and texture match, Minimal donor site morbidity [1]
Disadvantages: Can be difficult to design, Partial / complete necrosis [1]
Examples: Nasolabial flap, Transposition flap, Bilobed flap, Rhomboid flap, Mustardé flap [1]
Why local flaps are preferred for facial reconstruction: Facial skin is unique — it has specific colour, texture, and thickness that cannot be matched by tissue from distant sites. Local flaps recruit adjacent facial skin, giving the best cosmetic match. However, they are limited by the amount of tissue available locally.
| Flap Type | Use |
|---|---|
| Nasolabial flap | Nasal defects, oral cavity/lip reconstruction; uses skin from nasolabial fold |
| Transposition flap | Moves tissue over intervening skin bridge |
| Bilobed flap | Nasal tip defects (distributes tension over two lobes) |
| Rhomboid flap | Various facial defects; geometric flap design |
| Mustardé flap | Lower eyelid reconstruction using cheek advancement |
Regional / Distant flaps [1]
These include:
- Pectoralis major myocutaneous flap (PMMC): the workhorse of H&N reconstruction before free flap era. Based on thoracoacromial artery. Used for oral cavity, oropharynx, hypopharynx defects.
- Deltopectoral flap: based on internal mammary perforators
- Latissimus dorsi flap: large muscle flap, useful for massive defects
- Trapezius flap: for posterior scalp/neck defects
These are "pedicled" flaps — they remain attached to their blood supply and are rotated into the defect. Their reach is limited by the arc of rotation.
Advantages: Particular flap for particular defect [1]
Disadvantages: Longer operative time, Expertise, Risk of flap necrosis [1]
Why free flaps are often the best choice in H&N reconstruction:
- You can choose the exact tissue composition needed (skin, muscle, bone, bowel)
- You can tailor the size and shape precisely to the defect
- They allow reconstruction of complex 3D defects (e.g. mandible + floor of mouth + external skin)
Common free flaps in H&N:
| Free Flap | Composition | Common Indication |
|---|---|---|
| Radial forearm free flap (RFFF) | Skin + subcutaneous tissue (thin, pliable) | Oral cavity, oropharynx soft tissue defects |
| Anterolateral thigh (ALT) flap | Skin + subcutaneous ± vastus lateralis muscle | Larger soft tissue defects, pharyngeal reconstruction |
| Fibula osteocutaneous flap | Bone + skin paddle | Mandibular reconstruction (gold standard) |
| Scapula flap | Bone ± skin | Maxillary/orbital reconstruction |
| Jejunal free flap | Bowel segment | Circumferential pharyngeal/oesophageal defects |
| Iliac crest (DCIA) flap | Bone ± skin | Mandibular reconstruction (alternative to fibula) |
Risk of free flap failure: Overall success rate is ~95-98% in experienced centres. Failure is due to venous thrombosis (most common cause), arterial thrombosis, or pedicle kinking. Close post-operative monitoring (hourly for first 24-48 hours: colour, temperature, capillary refill, Doppler signal) is essential.
From GC 219 [2]:
Management Framework: Tumour clearance with long term survival benefit + Organ and function preservation. When surgery is indicated → Resection with adequate margins, Reconstruction for Form and Function, Rehabilitation always — swallowing, voice, and hearing [2]
From CFB 26 [6]:
- Voice prosthesis inserted for patients after total laryngectomy allows them to speak again
- Free cutaneous flaps after intraoral tumour resection improve tongue mobility → better function
- Free osteocutaneous flaps for mandibular reconstruction restore swallowing and speech
- Cochlear implantation for post-treatment profound deafness
- Radical resection of laryngopharynx + reconstruction with myocutaneous flaps or free jejunal grafts [6]
This is closely related to H&N cancer management and frequently examined:
| Type | What Is Removed | Indication |
|---|---|---|
| Selective neck dissection | Selected levels (e.g. I-III or I-IV) | No clinical LN involvement but high risk of occult metastasis ( > 15-20%) [3] |
| Modified radical neck dissection (MRND) | Level I-V LN; preserves ≥1 of: IJV, CN XI, SCM | Clinical LN involvement without invasion of preserved structures [3] |
| Radical neck dissection (RND) | Level I-V LN + IJV + CN XI + SCM | LN involvement with invasion of IJV/CN XI/SCM [3] |
High Yield — When to Do Prophylactic Neck Dissection
Prophylactic LN dissection is generally performed for H&N cancer when the risk of LN involvement > 15-20% depending on tumour type and TNM staging. [3]
Clinical Approach: H&N Cancer Patient
- Presenting complaint: ulcer, mass, pain, dysphagia, hoarseness, neck lump, bleeding, weight loss
- Duration and progression: rapidly growing → more aggressive
- Functional symptoms: difficulty swallowing (which phase?), voice change (phonation vs. articulation), breathing difficulty, ear symptoms (referred otalgia via CN IX/X)
- Risk factors: smoking, alcohol, betel nut, HPV exposure, EBV (NPC), prior radiation, occupational exposures
- Red flags: cranial nerve palsies, trismus, otalgia, weight loss
- Past medical history: previous H&N cancer (risk of second primary), immunosuppression
- Inspection: visible mass, ulcer characteristics (everted vs. inverted edge), skin changes
- Palpation: size, consistency, fixity, tenderness
- Oral cavity exam: floor of mouth, tongue mobility (fixed tongue = deep invasion), hard/soft palate
- Cranial nerve exam: VII (facial asymmetry), IX/X (palatal movement, gag), XI (shoulder shrug), XII (tongue deviation)
- Neck exam: cervical lymph nodes by level (I-VI), bilateral
- Nasendoscopy/Laryngoscopy: visualize nasopharynx, oropharynx, larynx
- Tissue diagnosis: FNAC of neck mass (first step for neck lump [11]), incisional biopsy of primary tumour, punch biopsy of skin lesion
- Imaging:
- CT neck + contrast: extent of tumour, bone invasion, lymph nodes
- MRI: soft tissue detail, perineural spread, skull base involvement
- PET-CT: detect distant metastases, second primaries
- CXR: lung metastases, second primary
- Panendoscopy: direct laryngoscopy + bronchoscopy + OGD (rule out synchronous second primary)
- Bloods: FBC, renal function, liver function, EBV serology (NPC)
- MDT discussion: surgeon, oncologist, radiologist, pathologist, speech therapist, dietitian
- Resection: adequate margins (tumour-type specific), ± neck dissection
- Reconstruction: individualized (ladder/elevator concept)
- Adjuvant therapy: RT ± concurrent chemotherapy for:
- Advanced stage (III/IV)
- Positive margins
- Perineural invasion
- Lymphovascular invasion
- Multiple positive nodes / extracapsular spread
- Rehabilitation: swallowing therapy, speech therapy, hearing rehabilitation, dental rehabilitation, prosthetics
- Follow-up: regular clinical exam + imaging to detect recurrence or second primary
Integration with Specific H&N Cancer Sub-sites
From the 2020 SAQ Q7 [7]:
- 4 cm tongue ulcer crossing midline + floor of mouth involvement + bilateral fixed neck nodes = advanced oral tongue SCC
- Diagnosis confirmed by: incisional biopsy / punch biopsy at ulcer edge
- Investigations for treatment planning: MRI head and neck, CT thorax, PET-CT
- Surgical treatment for best survival and function: wide excision (glossectomy) + bilateral neck dissection + free flap reconstruction (e.g. radial forearm or ALT flap)
- Adjuvant treatment: concurrent chemoradiotherapy (for advanced disease with adverse features)
From 2023 MCQ Q64 [10]:
- T1N0 NPC (confined to nasopharynx, no LN) → Intensity modulated radiotherapy (IMRT) is the most appropriate treatment (not surgery, not chemo-RT for early stage)
- Early glottic: RT (excellent cure rate, voice preservation)
- Advanced: Total laryngectomy + voice rehabilitation (TEP) OR concurrent CRT (organ preservation)
Inevitably exposed regions of the body — Systemic metastasis uncommon, reasonable life-expectancy [1]
This combination makes cosmetic reconstruction essential. Patients will live for years with the results of your surgery. A poorly reconstructed face causes:
- Social withdrawal
- Depression
- Difficulty with employment
- Inability to eat in public
- Stigma
"Head and neck cancer poses special challenges in both resection and reconstruction. Individualize the option of surgery to achieve the best functional and cosmetic result." [1]
| Trap | Correct Understanding |
|---|---|
| Confusing graft and flap | Graft = no blood supply, needs vascularized bed. Flap = brings its own blood supply. |
| Assuming reconstructive ladder must be followed in order | The lecture says the ladder "does not take into account aesthetic and functional result" — choose the BEST option, not simplest [1] |
| BCC margin = SCC margin | BCC 3-5mm, SCC 5-15mm — different biological behaviour |
| All H&N cancers treated with surgery first | NPC is treated primarily with RT ± chemo. Laryngeal cancer (early) is treated with RT for voice preservation. |
| Hoarseness = supraglottic cancer | Hoarseness = glottic (vocal cord) involvement. Supraglottic presents with dysphagia/otalgia first. |
| FNAC vs. incisional biopsy for neck mass | FNAC is the first-step investigation — incisional biopsy risks tumour seeding and disrupts tissue planes [11] |
| Inverted edge = SCC | Inverted/rolled edge = BCC; Everted edge = SCC |
| Post-laryngectomy voice: electrolarynx is best | TEP with speaking valve gives the best voice quality. Electrolarynx sounds robotic. |
| Taste loss after chemo is permanent | Taste loss after chemo is temporary; after RT/surgery it can be permanent [1] |
| Dysphagia after H&N treatment is always immediate | Sometimes delayed presentation after radiotherapy (fibrosis, stricture) [1] |
| Adenoid cystic carcinoma = aggressive early death | Adenoid cystic has indolent distant metastases — patients survive years even with lung mets (2022 MCQ Q12 discriminator) [12] |
High Yield Summary
- Key Points for Exam
- H&N region has vital organs in a small, exposed area — cancer/treatment affects function AND form
- Five major functions at risk: Vision, Airway, Taste, Swallowing, Speech
- Most H&N cancers = SCC; rarely metastasize distantly → patients live long with treatment consequences → reconstruction is critical
- Resection margins: BCC 3-5mm, SCC 5-15mm, Melanoma 5-30mm, DFSP 30-50mm
- Graft vs. Flap: Graft needs recipient bed blood supply; Flap brings its own blood supply
- Reconstructive Ladder: primary closure → skin graft → local flap → regional flap → free flap (but choose the BEST option, not the simplest)
- Speech rehabilitation post-laryngectomy: oesophageal speech, pneumatic device, electrolarynx, TEP with speaking valve (best quality)
- Swallowing problems: voluntary phase affected; immediate after surgery; delayed after RT
- Always protect the airway. Always plan resection and reconstruction together.
- MDT approach + rehabilitation (swallowing, voice, hearing) are essential
Active Recall - Lecture Notes
[1] Lecture slides: GC 187. Head and neck cancer problems Function and shape.pdf [2] Lecture slides: GC 219. Infections and tumours in pharynx and oral cavity.pdf (p44) [3] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai).pdf (p1603) [4] Senior notes: Maksim Surgery Notes.pdf (p63, p195) [5] Senior notes: MBBS Final MB (Surgery) (Felix PY Lai).pdf (p237, p258) [6] Lecture slides: CFB 26_Lecture Note_ENT (I).pdf (p2) [7] Past papers: 2020 Fourth Summative SAQ.pdf (Q7) [9] Senior notes: Ryan Ho Rheumatology.pdf (p187, p189) [10] Past papers: 2023 Fourth Summative MCQ.pdf (Q64) [11] Past papers: 2025 Fourth Summative MCQ.pdf (Q21-25, Q65) [12] Past papers: 2022 Fourth Summative MCQ.pdf (Q11-15)
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