Patient and family concerns:

Since the patient was old and frail with significant comorbidities, family was concerned if she will be able to withstand surgery. The family also wanted to know if there was any alternative to surgery.

Treatment offered:

• Biopsy of the tumor to confirm the diagnosis of cancer
• MRI of the head and neck to understand the spread of the tumor.

Biopsy of the tumor revealed sarcomatoid type of squamous cell cancer of the hard palate.

MRI scan showed that the tumor was eroding the hard palate and posterior wall of maxilla. It was invading the pterygomaxillary fissure as well. There was no spread to the lymph nodes. This meant the tumor was close to the origin of muscles of mastication on the left side. These muscles arise from the base of the skull.

Since this type of cancer does not respond to chemotherapy or radiation, surgery was the only option for this patient.

However, surgery meant possibility of complications due to patient’s age, nutritional debility and other risk factors. This was discussed in detail with the family.

Challenges in treatment:

Before the surgery patient’s nutritional status had to be improved. Her neurological status was thoroughly evaluated by an experienced neurologist. The complexity of the surgery meant it had to be performed in a tertiary care hospital with excellent critical care team. There was a possibility of bleeding from the tumor since it was a very vascular.

Further plan

1. Feeding the patient via naso-gastric tube to improve her nutrition: With this patient gained weight and felt more energetic.
2. Surgery was planned in a tertiary care center which had excellent ICU facility, Cardiology and Neurology services, good physiotherapy  and nutrition team.
3. Surgery meant removal of the major portion of hard palate and left maxilla along with the pterygoid muscles and plates to achieve clear resection (along with neck dissection).  Because of the size of the tumour and its spread posteriorly, it was not possible to perform the surgery with the standard Weber Ferguson incision that is commonly used. Hence access mandibulotomy approach was used in this patient. In this approach the mandible (lower jaw) is divided and swung laterally to gain access to the deeper parts of tumor. This is essential to remove the tumor  completely.

With the help of this unique approach the tumor was removed with safe margins.

We knew that a free flap meant a little longer operative time, but the defect was too large and too high to be covered by other methods. After the insertion of the free flap, the lower jaw was placed in its position with the help of the screws. A tracheostomy was done at the beginning of the surgery to secure the airway.

Post-operative recovery:

1. The operative site healed without any complications. Patient developed respiratory infection postoperatively which was managed conservatively with antibiotics, aggressive chest physiotherapy and pulmonary toileting. She was discharged 12 days after surgery.  She underwent swallowing therapy and was taken off feeding tube 4 weeks after surgery.
2. She completed her chemotherapy and radiation. She continues to be under follow-up.

Take home message:

Complex head and neck surgeries can be performed safely even in high risk patients when necessary care is taken. Innovative and unique approaches are sometimes necessary for successful surgical outcomes. Optimizing patients’ health before surgery ensures safety and reduces post-operative complications.