Oncology Oral Pathology

Mouth Cancer – Surgical Management

A Note On Surgical Management of  Mouth Cancer

Oral epithelium

– Squamous cell carcinoma
– Basal cell carcinoma
– Malignant melanoma

Salivary glands

– Benign
– Malignant

Muscles
Bone
Metastatic tumours
Nerves
Blood Vessels, Lymphatics

Mouth Cancer – Surgical Management
Mouth Cancer – Surgical Management
Mouth Cancer – Surgical Management
Mouth Cancer – Surgical Management
Mouth Cancer – Surgical Management

Multidisciplinary approach in the management

OMF Surgeon
Oncologist
Pathologist
Anaesthetist
Prosthodontist
Psychologist
Nursing staff
Cancer care workers
Others

Available treatments

1.Curative treatment
2.Paliative treatment
3.Terminal care

Curative treatments

Surgical treatment
Radiotherapy (curative,Adjuvant,Neo adjuvant)
Chemotherapy
– Chemo prevention
– Chemotherapy
Combination
Gene therapy
Photo sensitisation

Pre operative care

Investigations
General medical condition:
Hematological- FBC (Hb,PCV), Clotting profile…
Bio chemical- Liver function, BU, SC, SE, FBS, UFR
CXR, ECG, 2D ECHO….
Primary lesion:
Adjuncts  to biopsy- methelene blue, Vel scope
FNAC, Biopsy, EUA
Endoscopy
Plain x-rays, CT, MRI, PET, Frozen section
Regional extension: Neck
USS, USS guided FNAC, sentinel node Bx, CT,MRI
Distant metastasis:
CXR, USS abdomen, Liver function, Brain CT, Bone scan
Donor site:
X rays, Doppler, Alan’s test.

Patient preparation

Consent
Appropriate referrals
Nutrition
Drugs: warfarin, Heparin, Anti
hypertensives, diabetic drugs….
General hygiene
Oral hygiene
Withdrawal syndrome
Orientation
Plates
Blood
Shaving
Avoid pricking on donor sites
Allen’s test
Doppler study
Surgical plates / obturators
Antibiotics

Surgical treatment

Excision of primary tumour
Neck dissection
Reconstruction
Rehabilitation
Social
Physical
Psychological
Follow up

Primary tumour resection

cheek resection(buccal mucosa only or full thickness)
mandibulectomy (alveolectomy, segmental, hemi)
Tongue- partial, hemi, subtotal
Maxillectomy
Composite defect

Mouth Cancer – Surgical Management
Mouth Cancer – Surgical Management

 Reconstruction

Mouth Cancer – Surgical Management

Local flaps
Random —- Advancement—Burrows ▲,VY,transpo
—- Pivot principle—rotational,transposion
Axial   —- fore head, naso labial
Distant flaps
Deltopectoral
PMMC
Latisimus Dorsi
Sternomastoid
Trapezius
Free flaps: RFFF, FFF, LD, R.ab, lat th

Karapandzic flaps

Mouth Cancer – Surgical Management

 

Bernard’s Technique

Mouth Cancer – Surgical Management

Free flaps

Mouth Cancer – Surgical Management

Naso labial  flap

Mouth Cancer – Surgical Management

Micro vascular surgery

Mouth Cancer – Surgical Management
Mouth Cancer – Surgical Management

Anesthetic considerations
Temperature
Pain control
Blood pressure
Hb
Primary and secondary ischemic time

Postoperative Care

01. Postoperative nursing care:
Trained nurse-1st 24-48 hrs, sterile suction,humidification, rescue stitch-facilitate tube replacement, slate/pad,pen.
02. Fixation of the tracheostomy tube:
Dif if dislodged within 48hrs, stitch to skin. Tapes are enough for 2nd tube, put on neutral position, knots one each side of the neck (1/3,2/3), should not tight-lymphatic obs, donot put across the pedicle.
03. Removal of secretions:
Excess secretions are inevitable, tube act as f.body,exposed to cold, dry air. Oozing blood. Suck every 30min, 4hrly-immediate post opp period.
04. Humidification:
Warming, humidification-prevent crusting of secretions. Hot water humidifiers, nebulizers through masks or   T tube to trachy tube. Instillation of saline into the trachea.
05. Changing of tracheostomy tube:
1st 48 hrs – cuffed tube, mandatory to use t.tube with inner & outer tubes, this facilitates cleaning
The 1st two changes in after 48hrs, slightly smaller tube can be inserted.
Thereafter twice a week to avoid infection & crusting.
Ask the pt to breath in & out, ask him to hold the breath in expiration (maximum diameter), then insert a tube.
Within 48hrs, insert a catheter in to the old tube as guide. Tracheal dilators, laryngoscope. Doctor should be present at 1st tube change.
06. Care of the inflatable cuff:
If its pressure exceeds the systolic blood pressure-ischemic necrosis.
Cuff should be inflated for the 1st12 hrs following surgery & during this time deflated for 5min every hour.
After 12-24 hr if there is no bleeding, or not ventilated, let down.
New high volume, low pressure cuffs are now available.
07. Breathing exercises:
Physiotherapist,
Is secretions are excessive, vigorous treatment by intermittent positive pressure breathing or inflated Ambu bag after suction has been performed.
Block for 24 hrs. if no difficulties-can be withdrawn. Wound dressings.
08. Dressings:
Changing regularly.
09. Drains:
Vacume should be maintained.
10. Leaking drains:
Saliva, air or infected secretions are accumulated underneath the skin flap.
Infection and wound breakdown.
Local packing with saline soaked swabs or jelonet rolls.
If exit hole is there-pursestring suture, push the tube in??, Opsite spray,adhessives to cover the hole.
11. Type of drainage:
After a radical ND:- within 1st24-48hrs entirely blood appro 200ml/day.
After 48-72hrs become serous,
After 4 days – usually only 25 ml in 24 hrs.
If a localized fistula occur pack & allow to heal by 2ry intention.
Presence of chyle or lymphatic leak within the d.tube. ????
12. Removal of drains:
Remove when it stops draining?????
If there is a problem-blockage-remove it-otherwise infection.
Should not be removed until the drainage is less than 25ml, colour become blood red to serum.
Sucking serum from capillaries.
Remove by the 4th or 5thday if the daily drainage has been consistent for 48hrs.
13. Intravenous fluid:
Head & neck Sx pts: NG tube, PEG, open gastrostomy or Jejunostomy. Usually not require parental feeds, can fed within 48hrs of operation.
In 1st 48hrs pt must not given too much water & salts—-pulmonary oedema.
Between the end of operation & next day morning—IV fluids (responsibility of the anesthetist & surgical team).
Blood & fluids if required. Through CVP line.
CVP can be removed if the pt – if Hb & electrolytes are normal, NG tolerating, CVP is not needed for any other solutions or antibiotics.
Urinary output ? Early hrs, fluid balance??
14. Oral feeding:
In major abdominal Sx-after GIT function.
H&N sx – can be given if bowel sounds have returned.
Can be fed from day 1.
NG tube, PEG, open gastrostomy or Jejunostomy where enteral feeding is anticipated for short period after Sx.
For longer periods-Preopp PEG under LA with sedation. PEG is helpful if the pt need post opp RT.
Full strength feeds providing about 2400 kcal in 24 hrs can be achieved on the 2nd day.
Pts who do not have above methods-IV nutrition (parental nutrition-TPN) for several day after sx. Cost??? Sepsis ???
15. DVT prophylaxis:
Pt assessment for high, moderate & low risk.
Low risk pts – mobilize early.
Moderate risk pts – early mobi, TED-graduated compression stokings.
High risk pts – including all H&N oncology pts – perioperative & post operative Sc LMW heparin (Tinzaparin 3500 units daily), until the pt mobile, along with TED.
16.Monitoring of flaps:
Local flaps:- require observation, distant pedicled flaps-observe for 1 week. (gross vascular changes…), revision may required.
MV free flaps:- constant monitoring, often go wrong in the 1st 48 hrs

Medications:

Antibiotics:
Prophylactic AB cover is indicated in a number of situations.
It is not required for clean Sx-superfi,parotidectomy, MRND. Last for < 3hrs.
Longer procedures, shaving-within 24hrs: short AB prophylactic cover (48hrs)
Co-amoxiclav or Cefuroxime.
Specific indications: anti MRSA therapy.
Main indication for prophylactic AB in H&N sx for-mouth pharynx,larynx, upper oesophagus.
Gram +ve cocci & anaerobes.
Gram –ve cocci- seldom present, colonize the mouth within 2-3 days.
Co-amoxiclav or Cefuroxime and Metronidazole.
Erythromycin – significant GIT upset, not tolerated IV.
If risk of post opp infection continue for 5 days.
If infected – swabs, culture & ABST.
Chest infection should be prevented.
Oral hygiene – important.
Thyroid & parathyroid replacement:
After total thyroidectomy, parathyroidectomy—Ca balance, thyroid hormone repla
Half life of thyroxine is 10 days, can start 1 week after the sx. Thyroxine 100ug/day, in elderly 50ug/day. On discharge 150ug/day

Dressings & Sutures:

Wound dressings- several ADR;
Make the wound warm
Macerated & liable to infection
Haematomas?
Small amount of gauze dressing to prevent small leak. Removed after 12-24 hrs.
Not a good idea to apply pressure bandages around the neck;
Occlude venous return via vertebral veins.
But  has a value after parotidectomy for 24hrs-prevent haematoma.
Sutures:
Skin sutures can be removed in 7 days,
Extend to 10 days if he received previous RT,
After laryngectomy 10 days to 2 weeks: tension, dif to remove with laryngectomy tube,
Monofilaments synthetic sutures can be left longer than silk,
(silk-micro abscesses within 72 hrs),
Intra oral Vicryl do not need  to be removed.

Post operative examination:

Twice a day:- H&N, chest, abdomen and calves.

Getting up:

As soon as possible after Sx,pt can propped up in bed at 45 degree to avoid lymphatic stasis.
Bilateral ND-never lie flat. Danger of cerebral oedema.
After carotid blow out pt must be nurse flat for 48hrs. Then raise by 1 pillow per day.
Pt should be walking freely around the ward within 72 hrs. helps to prevent post op chest infection & DVT.

Follow up:

risk of developing recurrent disease,
Should be followed up at regular intervals,
In each follow up visit-examine;
Primary site for recurrence
Neck for LN
LN met is more likely to present within 1st 2 years.

Mouth Cancer – Surgical Management