by years of radiation was saved by Bengaluru doctors in a rare surgery
By : Dr Narayana Subramaniam
Lead Consultant – Head and Neck Surgery & Oncology, Aster Whitefield Hospital
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The several-hour-long complex microvascular reconstructive surgery was done in stages because of the size and complexity of the wound.
Radiation therapy is one of the most popular cancer treatments worldwide, but it comes with its own share of side effects. Besides the cancer cells, some of the normal tissue around the treated area may also be killed. In some extreme cases, the damage aggravates way beyond control. Speaking to indianexpress.com, Dr Narayana Subramaniam, Lead Consultant – Head and Neck Surgery & Oncology, Aster Whitefield Hospital, shares a rare case where a 70-year-old oral cancer patient came to the hospital with his “mouth exposed inside out.”
What led to this?
Dr Subramaniam explains that prolonged exposure to radiation therapy, in extreme cases, can lead to fibrosis, impaired healing, infection risk, open wound formation, or osteoradionecrosis — a condition wherein the jaw begins to decay. The patient had undergone three major cancer surgeries and two rounds of radiation earlier, which led to “severe fibrosis” making tissues very difficult to operate on.
As the bone decayed, it became infected, and the body began rejecting it. The dead bone slowly pushed outward, causing a large open wound on his face. This led to an oro-cutaneous fistula, meaning the inside of his mouth opened directly onto the skin.
“Critically, his carotid artery in the neck was exposed through the wound, placing him at constant risk of catastrophic bleeding that could result in death within minutes,” the surgeon notes. With no tissue covering the artery, even a small injury or infection could cause the artery to rupture, leading to sudden and fatal bleeding within minutes. “Every time radiation is given, tissues become fibrotic and very difficult to operate on. On top of that, he had osteoradionecrosis, malnutrition, infection, and an open wound that was a surgical minefield,” the surgeon notes.
A risky and unusual surgery
Surgery in such cases usually involves removing dead tissue and starting Hyperbaric Oxygen Therapy (HBOT) to aid healing in radiation-damaged areas. In this case, however, the patient suffered a stroke due to a clot in the exposed vessel just before the surgery. “Normally, we wait 10–16 weeks after a stroke,” said Dr Narayana Subramaniam. “But waiting was not an option here.” With the carotid artery at risk of rupture, surgeons operated just four weeks later. They used an Anterolateral Thigh (ALT) free flap to rebuild the jaw, connecting it to vessels on the opposite side of the neck due to radiation damage. “The surgery was done only to prevent sudden death and restore quality of life,” Dr Subramaniam said.
Warning Signs
Osteoradionecrosis and tissue fibrosis are extremely critical conditions. The patient should keep an eye on given symptoms during their chemotherapy for timely medical intervention: a sore or ulcer on the gums, neck or outer jaw, pain, swelling, infection, malocclusion (misaligned teeth), numbness or tingling, exposed bone inside the mouth, bone protruding through the skin (fistula) usually under the jaw, broken jawbone (fracture), tight jaw muscles that limit mouth opening (trismus). It is very important to maintain oral hygiene during this while.