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Pre-treatment clinical assessment in head and neck cancer: United Kingdom National Multidisciplinary Guidelines
- A Robson, J Sturman, P Williamson, P Conboy, S Penney, H Wood
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- Journal:
- The Journal of Laryngology & Otology / Volume 130 / Issue S2 / May 2016
- Published online by Cambridge University Press:
- 12 May 2016, pp. S13-S22
- Print publication:
- May 2016
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This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. This paper provides recommendations on the pre-treatment clinical assessment of patients presenting with head and neck cancer.
Recommendations• Comorbidity data should be collected as it is important in the analysis of survival, quality of life and functional outcomes after treatment as well as for comparing results of different treatment regimens and different centres. (R)
• Patients with hypertension of over 180/110 or associated target organ damage, should have antihypertensive medication started pre-operatively as per British Hypertension Society guidelines. (R)
• Rapidly correcting pre-operative hypertension with beta blockade appears to cause higher mortality due to stroke and hypotension and should not be used. (R)
• Patients with poorly controlled or unstable ischaemic heart disease should be referred for cardiology assessment pre-operatively. (G)
• Patients within one year of drug eluting stents should be discussed with the cardiologist who was responsible for their percutaneous coronary intervention pre-operatively with regard to cessation of antiplatelet medication due to risk of stent thrombosis. (G)
• Patients with multiple recent stents should be managed in a centre with access to interventional cardiology. (G)
• Surgery after myocardial infarction should be delayed if possible to reduce mortality risk. (R)
• Patients with critical aortic stenosis (AS) should be considered for pre-operative intervention. (G)
• Clopidogrel should be discontinued 7 days pre-operatively; warfarin should be discontinued 5 days pre-operatively. (R)
• Patients with thromboembolic disease or artificial heart valves require heparin therapy to bridge peri-operative warfarin cessation, this should start 2 days after last warfarin dose. (R)
• Cardiac drugs other than angotensin-converting enzyme inhibitors and angiotensin II antagonists should be continued including on the day of surgery. (R)
• Angotensin-converting enzyme inhibitors and angiotensin II antagonists should be withheld on the day of surgery unless they are for the treatment of heart failure. (R)
• Post-operative care in a critical care area should be considered for patients with heart failure or significant diastolic dysfunction. (R)
• Patients with respiratory disease should have their peri-operative respiratory failure risk assessed and critical care booked accordingly. (G)
• Patients with severe lung disease should be assessed for right heart disease pre-operatively. (G)
• Patients with pulmonary hypertension and right heart failure will be at extraordinarily high risk and should have the need for surgery re-evaluated. (G)
• Perioperative glucose readings should be kept within 4–12 mmol/l. (R)
• Patients with a high HbA1C facing urgent surgery should have their diabetes management assessed by a diabetes specialist. (G)
• Insulin-dependent diabetic patients must not omit insulin for more than one missed meal and will therefore require an insulin replacement regime. (R)
• Patients taking more than 5 mg of prednisolone daily should have steroid replacement in the peri-operative period. (R)
• Consider proton pump therapy for patients taking steroids in the peri-operative phase if they fit higher risk criteria. (R)
• Surgery within three months of stroke carries high risk of further stroke and should be delayed if possible. (R)
• Patients with rheumatoid arthritis should have flexion/extension views assessed by a senior radiologist pre-operatively. (R)
• Patients at risk of post-operative cognitive dysfunction and delirium should be highlighted at pre-operative assessment. (G)
• Patients with Parkinson's disease (PD) must have enteral access so drugs can be given intra-operatively. Liaison with a specialist in PD is essential. (R)
• Intravenous iron should be considered for anaemia in the urgent head and neck cancer patient. (G)
• Preoperative blood transfusion should be avoided where possible. (R)
• Where pre-operative transfusion is essential it should be completed 24–48 hours pre-operatively. (R)
• An accurate alcohol intake assessment should be completed for all patients. (G)
• Patients considered to have a high level of alcohol dependency should be considered for active in-patient withdrawal at least 48 hours pre-operatively in liaison with relevant specialists. (R)
• Parenteral B vitamins should be given routinely on admission to alcohol-dependent patients. (R)
• Smoking cessation, commenced preferably six weeks before surgery, decreases the incidence of post-operative complications. (R)
• Antibiotics are necessary for clean-contaminated head and neck surgery, but unnecessary for clean surgery. (R)
• Antibiotics should be administered up to 60 minutes before skin incision, as close to the time of incision as possible. (R)
• Antibiotic regimes longer than 24 hours have no additional benefit in clean-contaminated head and neck surgery. (R)
• Repeat intra-operative antibiotic dosing should be considered for longer surgeries or where there is major blood loss. (R)
• Local antibiotic policies should be developed and adhered to due to local resistance patterns. (G)
• Individual assessment for venous thromboembolism (VTE) risk and bleeding risk should occur on admission and be reassessed throughout the patients' stay. (G)
• Mechanical prophylaxis for VTE is recommended for all patients with one or more risk factors for VTE. (R)
• Patients with additional risk factors of VTE and low bleeding risk should have low molecular weight heparin at prophylactic dose or unfractionated heparin if they have severe renal impairment. (R)
Perforation after rigid pharyngo-oesophagoscopy: when do symptoms and signs develop?
- M Daniel, T Kamani, C Nogueira, M-C Jaberoo, P Conboy, M Johnston, P Bradley
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- Journal:
- The Journal of Laryngology & Otology / Volume 124 / Issue 2 / February 2010
- Published online by Cambridge University Press:
- 20 October 2009, pp. 171-174
- Print publication:
- February 2010
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Background:
Perforation after pharyngo-oesophagoscopy is a serious complication, and its identification, through close patient monitoring, is essential. Yet little is known about when symptoms and signs develop, and thus how long any close monitoring should last.
Aim:To examine the timing of individual symptoms and signs of perforation after rigid pharyngo-oesophagoscopy.
Methodology:Three-centre, retrospective study.
Results:Of 3459 patients undergoing rigid pharyngo-oesophagoscopy, 10 (0.29 per cent) developed perforations, nine of which were suspected intra-operatively. Symptoms and signs developed at 1.5 hours post-operatively at the earliest, and at 36 hours at the latest. Three patients were asymptomatic. The majority of procedures (n = 8) were undertaken for food bolus obstruction or foreign body ingestion.
Conclusion:Pharyngo-oesophagoscopy for food bolus obstruction and foreign body ingestion accounts for a large number of perforations, but symptoms and signs may take longer than 24 hours to develop. A contrast swallow should be considered in high risk patients, and a high index of suspicion maintained in order to detect this complication.
Idiopathic diffuse erosion of the skull base presenting as cerebrospinal fluid rhinorrhoea
- P. J. Conboy, I. J. M. Johnson, T. Jaspan, N. S. Jones
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- Journal:
- The Journal of Laryngology & Otology / Volume 112 / Issue 7 / July 1998
- Published online by Cambridge University Press:
- 29 June 2007, pp. 679-681
- Print publication:
- July 1998
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We present an unusual case of generalized erosion of the skull base. We have not found a similar case reported in the world literature. The presenting symptom was spontaneous cerebrospinal fluid (CSF) rhinorrhoea which arose from a bony defect associated with herniation of the right temporal lobe into the sphenoid sinus. We discuss the management of such a case including imaging of the skull base and the endoscopic repair of the bony defect.