Operative Surgery for Head and Neck Tumors

Jagdeep Thakur, Ripu Daman Arora, Jagdeep Thakur, Ripu Daman Arora

• Publisher: CRC Press
• Year: 2021
• ISBN:
  9781000510119
• Edition: 1
• Topic: Medicina
• Subtopic: Otorinolaringoiatria

This book emphasizes on clinical, radiological and laboratory assessment of operative surgery in common head and neck surgical procedures. It provides a systematic and rational operative approach to management in day-to-day practice. A photographic style is used, wherein high-quality photographs provide visual details to reveal each step of the procedure. This photographic content of each surgical step on patient or cadaver makes this book a valuable resource for surgical residents, fellows, junior consultants, and general surgeons who manage head and neck cases and would learn to deftly perform the procedures.

Key Features
• Incorporates a unique photographic style enumerating the step-by-step surgical procedures.
• Provides a crisp and to the point approach towards common head and neck surgical management, helpful for surgery residents and trainees.
• Fills a significant gap for a text that adequately describes the wide variety of procedures performed by head and neck surgeons.

1The Head and Neck Team

Jagdeep Thakur S

DOI: 10.1201/9780367430139-1

The Team

“Alone we can do so little; together we can do wonders.”

(Modified from the words of Helen Keller)

The head and neck team consists of more than the surgeon – it’s a multidisciplinary team. Typically, the team is led and coordinated by a head and neck surgeon and consists of

• Head and neck surgeon
• Radiation oncologist
• Medical oncologist
• Radiologist
• Pathologist
• Reconstructive surgeon
• Prosthodontist
• Speech therapist
• Oncology nurse
• Physiotherapist
• Nutritional specialist
• Allied specialists: anaesthetist, neurosurgeon, ophthalmologist, psychiatrist, audiologist

However, we consider the patient an important member of the team around whom everything revolves.

To become a surgeon one needs to be good anatomist, a lifelong observer and learner and a good communicator. The old saying “It takes a few years to learn how to do surgery, another few years to learn when to do surgery, and a decade to learn when not to do surgery” holds true.

A surgeon should observe and learn from everyone around him/her while in the operating room. One should never hesitate to ask for help from a senior or junior whenever there is a doubt, especially in difficult cases where you need to review anatomy and can ask your assistant or other operating team member for a clue.

You should always have a look at the monitor or talk to the anaesthetist while operating to check the vitals of the patient. A surgeon should be confident but not overconfident. He/she should know the team’s capabilities and limitations, and there should be another specialist on hand who can help in case of any complication. It is always better not to start when you cannot finish, and this rule should be strictly followed in oncology cases to avert the need for revision surgery. One should always review the case before surgery and remain calm and confident. Any vascular breach should not be clamped blindly as it will further lead to complication especially neural injury. Digital pressure is the safest method to control haemorrhage, and once proper instruments become available, one should try to use the clamp under direct vision. At the end of surgery, always check cavities for any leftover gauges, needles, or instruments, and check for haemorrhage with raised intrathoracic pressure. Secure the drain at appropriate area with absorbable sutures. Skin closure should always be directly observed if being done by residents. Just before dressing the surgical site, make sure the drain is secured and negative pressure is maintained.

A subject/patient is the pivot of the surgical team as treatment planning and outcome directly depends upon him/her. First and foremost, patients should have full information on the disease and its management options. Counselling is an art and the surgeon should have good communication skills and confidence. These skills improve with time, but there are a number of free online modules from various educational institutes. The patient should know that he/she is in good hands. She/he should be told about positive things of surgery first and then about post-operative complications. Once he/she gives consent for surgery, patient should be informed about operative defects, reconstruction and post-operative care, radiotherapy and morbidity. The expected complications or poor outcome must be disclosed when the patient is fully prepared for surgery. This mental preparation will result in better outcome.

The radiologist should be specifically requested to evaluate and report on areas of interest if he/she is unaware of surgical approach or resection area. The surgeon should always read the CT and MRI to see the extent of the disease and plan the surgery accordingly, rather than reading the radiologist’s report, and whenever in doubt it is better to go to the radiologist who can reconstruct the images according to the surgeon’s plan. Further, the radiologist should specifically be requested to comment on the nature of nodes so that cytological diagnosis can be made for further planning of neck dissection. Nowadays, certain benign cysts can be managed by an interventional radiologist and hence surgery may be avoided.

The pathologist also must be provided with full clinical and imaging details as sometimes it’s difficult for him/her to make a pathological diagnosis. Excised tissue should be marked at the time of surgery as later it becomes difficult to label due to loss of orientation.

The anaesthetist needs to be informed on the nature of the surgery and impending complications, if any. In head-neck surgery, the surgeon and the anaesthetist have a common work area, hence coordination and mutual trust are of utmost importance for optimal operative and post-operative outcome.

The reconstructive surgeon/prosthodontist should know the surgical plan and expected defect to plan reconstruction. The patient should have full information on defect and reconstruction options. This will help the patient to cope and reduce post-operative morbidity.

The surgeon should discuss the treatment plan with the radiotherapist. Many times a tumour may not be resectable and pre-operative chemo-radiation can help in such cases. After surgery, the radiotherapist should have full information on operative findings to plan further treatment.

The speech therapist and physiotherapist are responsible for helping the patient in reducing post-operative morbidity. They should also know the probable post-operative morbidity so that they can counsel the patient and family members pre-operatively. This will improve the patient and family members quality of life.

The oncology nurse is mainly involved during chemotherapy in head and neck tumours. Anticancer drugs have many side effects and carry risk of complications. A well aware oncology nurse brings down these side effects or complications to the minimal.

The allied specialties like pain management, neurosurgeon or ophthalmologist join the head and neck team routinely due to anatomical or physiological need of the disease. The audiologist is required in management of cases involving ear or temporal bone. Patients undergoing chemoradiation usually require evaluation by an audiologist for proper rehabilitation.

2Pre-Operative Management

Dara Singh

DOI: 10.1201/9780367430139-2

INTRODUCTION

Pre-operative preparation of a surgical patient starts with the diagnosis and planning of surgery. In most of surgical centres, the senior resident or most senior resident of the unit is responsible for all the planning, preparation and optimisation of a surgical patient. Assessment and optimisation of patients is important to prevent unnecessary cancellations of surgery, smooth conduct of anaesthesia and surgical procedure, and to avoid peri-operative morbidity and mortality.

During the planning for surgery, the following points must be paid special attention:

• Pre-admission planning
• Pre-admission patient education
• Patient screening on OPD basis
• Optimisation of patient in terms of
  • o Head and neck
  • o Cardiovascular system
  • o Respiratory system
  • o Diabetes
  • o Renal and hepatic
  • o Haematology
  • o Drug allergies
• Pre-anaesthetic check-up

Pre-Admission Planning

When the patient first consults the surgeon, the pre-admission plan should start in the surgeon’s mind. It should include the diagnosis, surgery planned, any radio- or chemotherapy required pre-operatively in malignant cases, any comorbid conditions needing pre-admission optimisation, nature of the surgery (that is, emergent, urgent or planned), any need for removal of tissue or part of it, impact of that removal on patient’s day-to-day activities, any loss of skin (if yes, a plan to repair that loss – i.e., flap or graft and type most suitable, e.g., rotational flap and how to raise it, graft split skin, partial or full thickness, etc.).

Pre-admission Education

Before talking to patient, imagine you are the patient: what would you like to know about the disease and surgery? Discuss with the patient and family options of treatment, cost of hospital stay, cost expected in post-operative period at home, change in lifestyle after planned treatment, any complications during and after the hospital stay. After discussing all the treatment options and planning the treatment, written informed consent must be obtained from patient. This consent should be written in clear words, in a language most suitable for the patient, explaining the diagnosis, treatment options and plan, along with the possible complications. The consent has to be attested to by one witness to safeguard the treating physician from post-treatment legal issues. When to obtain consent depends on hospital protocol and can vary, from outpatient department (OPD) file preparation to hospital admission to before operative procedure.

Screening Pre-Anaesthetic Check (PAC)

Patient should be screened in anaesthesia OPD on the day of presentation to surgical OPD to ensure that no unnecessary fitness investigations are carried out. This can also decrease the hospital admission days by guiding the fitness of patient for surgery and hence determining the right time to admit the patient for surgery.

Optimisation of the Patient

While planning for optimisation, one must follow a set sequence (follow hospital protocols) to avoid missing any important organ or system. Organs or systems with more frequent comorbid conditions should be dealt with or screened with special attention, e.g., cardiovascular (hypertension, ischaemic heart diseases), endocrine (diabetes mellitus), respiratory (chronic obstructive pulmonary disease/asthma) and haematological system (anaemia, antiplatelets or anticoagulant treatment). Metastasis and/or any paraneoplastic symptoms should be paid special attention in case of cancer. Second primary malignant tumour or synchronous malignancies are common in certain head-neck cancers, e.g., aerodigestive epithelial cancers and MEN syndrome.

It is also recommended to discuss the following issues with patient:

• Risk prediction due to primary disease and comorbid conditions
• Surgical and anaesthetic implications
• Expectant functional outcome
• Effect on quality of life

In head and neck preparation and optimisation, airway assessment carries utmost importance. A difficult airway at the time of anaesthesia may give rise to unforeseen morbidity or mortality. Airway assessment and investigations should be started before contacting the anaesthesiologist. Any direct or indirect compression or occlusion of airway found on clinical examination and radiological investigations should be documented and investigated thoroughly. Elective tracheostomy should be planned and discussed with the patient and anaesthesia team well in advance. Similarly, post-operative care in case of reconstructive surgery or airway surgery that may require intensive care should be planned.

In case of malignancies of head and neck, a multidisciplinary discussion involving other concerned specialities (e.g., medical oncology, radiation oncology, plastic surgery and anaesthesia) helps the primary treating physician in choosing an appropriate treatment plan.

Functional status of thyroid and parathyroid glands must be looked for in thyroid tumours or swellings. Some malignant tumours involving these glands may also affect their hormonal status, apart from other thyroid swellings. Hypothyroidism requires optimisation for at least 10–15 days, while hyperthyroidism may take longer duration, 4–6 weeks for the same. A euthyroid status should be ensured before planned surgery in patients of a non-emergency nature.

Hypertension is one of the commonest comorbidities in surgical patients across all specialties. It has been observed that nearly half the number of ...