Preoperative Counseling and Patient/Relation Education

The benign and malignant diseases outlined in this book often require frank and detailed discussion with the patients and other family members. The topics covered are many and varied but may include:

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  Pain control

  
  
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  The effects of any environmental exposure at work

  
  
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  Smoking, alcohol use, obesity, and lifestyle in general

  
  
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  Poor nutrition, weight loss

  
  
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  The individual fears of cancer of both the patient and family

  
  
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  The issues related to the upcoming surgery, radiotherapy, and/or chemotherapy

  
  
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  The early and long-term postoperative treatment in relation to breathing, speech, swallowing, cosmesis, eyesight, smell, taste, hearing, and restoration of normal or limited activities

Lack of information with regard to the potential changes, morbidity, and indeed mortality, often leads to inadequate ability of the patients and their families to cope, not only with the possibilities of even moderate or major surgery but with the issues of radiotherapy and chemotherapy. Obtaining informed consent from this group of patients requires care and time, and while this is not always easily available in a busy therapeutic, tertiary referral practice, it is extremely important to put aside this time and for all the members of the multidisciplinary team to be well informed with regard to the patient′s preoperative situation. A high proportion of these patients present with advanced disease with a far from certain outcome as to whether or not they can be cured; it is important to establish a real and definite area of cooperation and trust within the multidisciplinary team, the patient, and their family. With specific surgical procedures often being done by one or more surgeons, it is important that one, and preferably more, of the surgeons take a specific interest in each patient along with their key worker, who is usually the clinical nurse specialist. While multidisciplinary team efforts have been advocated for many years, it is still essential that a main operating surgeon and the patient have appropriate time together to discuss the overall situation, both pre- and postoperatively.

The Head and Neck Clinical Nurse Specialist

In the United Kingdom, the clinical nurse specialists are frequently former senior nurses and many of them have been ward sisters on head and neck and neurosurgical wards. As such, they are advocates for the patients and have considerable clinical nursing expertise, but added to this, many of them understand the roles of all the staff involved in the multidisciplinary team and can act as advisers, counselors, teachers, and researchers and generally liaise throughout the team. They are specifically able to provide continuity of care for the patients and must be involved from a point of early initial contact right through to discharge to home and subsequent communications with the family practitioner, visits to home, and the patient′s return to the clinic. This is a demanding but incredibly satisfying role for the right individual and another keystone for improved care for the patient. They are however, not a substitute for full and careful communication between the treating physician/surgeon and the patient.

Initial Assessment and Symptom Management

Patients with relatively early tumors of the nose, paranasal sinuses, and skull base may have little in the way of symptoms as alluded to above, but any that present late or having had previous failed treatment do have important problems with regard to pain control and symptoms such as epistaxis, epiphora or double vision, trismus, dental problems, and so on. While immediate consideration is given to establishing an accurate diagnosis if this has not already been undertaken, it is important before considering investigations, or certainly at the same time, for the consulting doctor and the team to address the patient′s pain control and other needs. Diseases of this area rarely result in major nutritional issues as most patients are still able to take food orally, unless the disease is so extensive as to involve the oral cavity or to produce severe trismus. However, weight loss, as with cancer in general, may already be significant and early assessment by the dietician, irrespective of the subsequent form of treatment, is essential.

Pain management is increasingly undertaken by specialist members of the team and morphine and its derivatives may be required immediately and, on occasion, immediate patient admission may be necessary to address the issues of pain and epistaxis. Only when these problems have been brought under control, should the team proceed with imaging, biopsies, and so forth.

Hospice Care

Unfortunately, advanced disease in these areas may be unresectable and inappropriate to be treated with either chemotherapy or radiotherapy; it is important that the multidisciplinary team agree on these issues and that the patient and the family receive immediate supportive care, and that any primary physicians receive adequate and early information with referral of the patient and family to an appropriate local hospice, if this exists in the country in which they present. When patients are transferred from hospital to hospice, or are returning to their home with appropriate primary care, pain control and nursing must be clearly communicated and documented to the ongoing carers.

Nutrition

The importance of nutrition in all forms of major head and neck tumor treatment cannot be overemphasized. As in other areas of cancer, there has been an increasing international literature over the last three decades that shows that it is important to establish nutritional parameters:

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   Prior to treatment

   
   
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   Throughout the treatment

   
   
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   During the posttreatment phase, particularly when combined therapy has been instituted

Patients with malignant disease of the nose, sinuses, and skull base are, unfortunately, no different from any others within the general population in that obesity, diabetes, respiratory, cardiovascular, and gastrointestinal disease and arthritis are all common accompanying factors. The overall weight of the patient and any loss or gain in recent times should be clearly established along with the present state of nutrition, which may require intervention and careful planning with correction prior to any major treatment considerations, either surgical, radiotherapeutic or chemotherapeutic. A nutritional plan is individualized for each patient and reassessed at regular intervals throughout any subsequent treatment. There is a wide variation in patients’ tolerance with regard to oral feeding or nasogastric or parental feeding with a wide variety of nutritional support and hence the need for a continuous and expert input if this is available. In those countries where dietetic/nutritionist expertise is not available these considerations must be taken on by the surgical team. Irrespective of the expertise of any surgeon, good postoperative results with low morbidity and mortality will not be obtained if operating on nutritionally compromised, dehydrated, and poorly prepared patients.

A proportion of patients with advanced disease of the skull base have significant cranial nerve deficits preoperatively, but these may be markedly increased following surgery and/or radiotherapy and may be accompanied by problems such as silent aspiration. In these patients, early assessment of these problems and their long-term care may be absolutely crucial to a successful outcome. They may require a full swallowing rehabilitation program and close cooperation between the nutritionists and speech therapists (speech pathologist).

Social Services

A proportion of the elderly patients who may present with diseases in this area will live on their own and may not have significant family support. For other patients, even ones who have significant family help, social service issues may need to be addressed from the outset and considered prior to any significant surgery. The important issues of coping on return to home may require adaptation. For instance, if it is necessary to remove the patient′s eye or maxilla or to carry out substantial facial reconstruction, then additional support may be necessary to help the patient cope with their subsequent return to home and, if possible, work. A patient′s comorbidity, dependence on alcohol, and drug history may also be part of the important mix of their requirements; social assessment and nursing evaluation needs, again, may be channeled through the clinical nurse specialist, depending on the circumstances within each given team or the country in which the patient is being treated. The patient may require a variety of aids both in and out of the home and help to deal with issues of disfigurement, mobility, ability to drive, and so on.

As in all forms of cancer surgery, occasionally, pre-treatment assessment may require expert psychiatric opinion and certainly this is necessary in a small number of patients who survive the more arduous forms of combined treatment and find it difficult to reestablish a reasonable quality of life.2 These issues cannot be ignored as the cure of many of these unfortunate patients is only the beginning of a long period of rehabilitation.

Dental Assessment; Osseointegration Prosthetics

The history of prosthetic rehabilitation after maxillectomy extends back to Syme in 1835. By the early part of the 20th century, prosthetic and dental restoration after maxillectomy were well developed, with Woodman′s seminal description of the technique of an initial plaster cast, a temporary denture, and subsequently a permanent denture, being described in 1923 (Fig. 19.5). These techniques have been continuously improved with the use of an ever-increasing range of modern materials so that in our own hospital, preoperative assessment and fashioning of an upper jaw prosthesis, which was subsequently placed at the time of the ablative surgery, dates back for more than 60 years (Fig. 19.6). In contrast, thorough pretreatment oral and dental evaluation by an oncologically orientated dentist documenting oral and dental pathology prior to any cancer treatment is far from universal. Many treating surgeons and physicians still fail to remember how important it is before treatment to reduce or remove any sources of potential infection and to consider osseointegrated implantation at the time of the ablative surgery to aid subsequent rehabilitation even if there is to be postoperative radiotherapy and chemotherapy. The surgeon, radiation oncologist, and medical oncologist should be able to assess oral pathology secondary to poor dental status, notably advanced periodontal disease, gross dental caries, poorly fitting existing dentures, and poor oral hygiene. As part of the initial assessment, the patient should be referred to a dental colleague to undertake thorough oral and dental assessment with appropriate radiographs, which may include occlusal, panoramic, periapical, and bitewing views. These are relatively easy and inexpensive investigations in comparison with CT and MRI and may be extremely important in the long-term care of the patient. This is particularly the case if an extensive nasal, paranasal, sinus, or skull base lesion involves the interior aspect of the upper jaw and prosthetic rehabilitation depends on stable anchorage of any prosthesis to remaining teeth on the opposite side (Fig. 19.7).

Teeth with potentially poor prognosis require extraction before postoperative chemotherapy or irradiation. With forward planning, this may be done under the same general anesthetic as the ablative surgery. Performing these removals at the time of the primary surgery may decrease the workload for the team and the waiting time for the patient. There is considerable potential room for improvement with regard to this aspect of patient care as subsequent osteoradionecrosis remains a serious and debilitating problem with a generally poor outcome. Dental assessment is frequently required in the postoperative and posttreatment period, particularly with patients who undergo additional irradiation because—even with the more modern techniques of IMRT—they may still experience some dry mouth (xerostomia) and an increased incidence of dental disease, particularly of the upper jaw in this group of patients. Patients may require continual encouragement to use simple measures such as a fluoride rinse and to attend their general dentist for routine care in the long term after their treatment.

There have been steady improvements in the extraoral application of osseointegrated techniques to allow improved retention of intraoral/maxillectomy/orbital/nasal/hemifacial prostheses in the last 20 years (see Chapter 21). While reconstruction of maxillectomy defects with free flaps is becoming increasingly popular in those countries able to undertake the technique, it does not always provide the best alternative to a well-constructed obturator prosthesis, particularly if the latter can be secured in an excellent manner on any remaining teeth and with additional osseointegrated implants. There are cases, particularly those patients who are edentulous, where the free flap reconstruction may offer an acceptable aesthetic and functional result, but in older patients the prolonged operating time may be a contraindication. In contrast, for some of the older edentulous patients and less capable individuals who are unable to maintain and accurately place a prosthesis, a free flap reconstruction may be beneficial. Careful consideration must be given to each individual patient.

Overview

Insufficient attention has frequently been paid in the past to understanding patients’ concerns with regard to proposed treatment of their nose, paranasal sinus, and skull base tumors. The multidisciplinary team needs to be sensitive to these issues and to understand that a patient′s ability to take in information under the stress of this situation is, to say the least, suboptimal. The use of medical terms rather than understandable everyday language is inappropriate, and the whole patient journey requires patients to be cared for and supported in a positive manner. The unique aspects of surgery in this region and the possibility of additional radiotherapy and chemotherapy require frank discussion with the patient and their family members; and the patient′s individual fears about why they have presented with these cancers and the issues around complications, morbidity, disfigurement, and overall changes from their normal activities require thorough discussion. Informed consent should be obtained by senior members of the team, preferably the consultant surgeon undertaking the procedure and with the clinical nurse specialist present. The patient, the relatives, and the team members will all benefit from the establishment of an atmosphere of mutual trust, particularly where the situation is likely to change over the passage of time, and there is always the possibility of failure of therapy or recurrence of disease in addition to the morbidity and occasional mortality.

Selection of a Particular Operative Procedure

In selecting a particular procedure for an individual patient, the site, size, histology, and natural history of the patient′s disease and any additional comorbidities are extremely important. Surgeons are influenced by their personal philosophy, past experience, and technical capability. A professional approach is required if patients who are curable are to be cured and the aim of any surgery is total removal of the tumor. Combined approaches to any cancer require the availability of a wide range of expertise and often individuals of compatible experience may not be available in most multidisciplinary clinics and democratic discussion may be weighted toward one particular discipline. In many countries, unfortunately, financial issues take part in the decision-making process and an undesirable, competitive element between different departments may further complicate the issues. However, if we are to improve the overall poor long-term control rates for many of these diseases, and the persistence of the crippling and mutilating effects of many surgical resections, then these procedures require careful consideration. Mere acquisition of multiple surgical technical skills does not necessarily produce appropriate selection for patients and this whole area is fraught with philosophical considerations. In particular, the advantages of successful surgery must outweigh the risks and subsequent morbidity and the surgeons must ask themselves whether they are able to perform the procedure to an accepted level of competence, bearing in mind what is the best treatment for any particular patient with any specific disease. If this is not the case, they should consider referring the case to a more experienced colleague or an alternative multidisciplinary team dealing specifically with these rare tumors.

Much of the surgery in this area aimed at cure or long-term palliation is associated with a degree of mutilation, and certainly notable interference with function. In some countries, such disabilities preclude social acceptance and facial disfigurement is still an important problem in most communities. Even excellent external prostheses only act as camouflage and considerable damage to the patient′s self-image may present a serious problem, with them requiring considerable support to return to work or other aspects of daily life (Figs. 19.8 and 19.9).

In contrast, however, electing a conservative procedure with little hope of cure may only allow the disease to progress and cause the patient far more in the way of symptoms prior to an unpleasant death. While the patient may pay a price for a “cure at any cost” philosophy, inadequate “debulking” and reliance on “chemotherapy” can produce devastating sequelae.