The Journal of laryngology and otology
-
Practice Guideline
Pre-treatment clinical assessment in head and neck cancer: United Kingdom National Multidisciplinary Guidelines.
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).
-
Practice Guideline
Investigation and management of the unknown primary with metastatic neck disease: United Kingdom National Multidisciplinary Guidelines.
This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. It discusses the evidence base pertaining to the management of metastatic neck disease in the setting of an unknown primary and provides recommendations on the work up and management for this group of patients receiving cancer care. Recommendations • All patients presenting with confirmed cervical lymph node metastatic squamous cell carcinoma and no apparent primary site should undergo: ○ Positron emission tomography-computed tomography whole-body scan. (R) ○ Panendoscopy and directed biopsies. (R) ○ Bilateral tonsillectomy. (R) • Tongue base mucosectomy can be offered if facilities and expertise exists. (G) • Concomitant chemotherapy with radiation should be considered in patients with an unknown primary. (R) • Concomitant chemotherapy with radiation should be offered to suitable patients in the post-operative setting, where indicated. (R) • Neo-adjuvant chemotherapy can be used in gross 'unresectable' disease. (R) • Patients should be followed up at least two months in the first two years and three to six months in the subsequent years. (G) • Patients should be followed up to a minimum of five years with a prolonged follow up for selected patients. (G) • Positron emission tomography-computed tomography scan at three to four months after treatment is a useful follow-up strategy for patients treated by chemoradiation therapy. (R).
-
Practice Guideline
Recurrent head and neck cancer: United Kingdom National Multidisciplinary Guidelines.
This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. Recurrent cancers present some of the most challenging management issues in head and neck surgical and oncological practice. This is rendered even more complex by the poor evidence base to support management options, the substantial implications that treatments can have on the function and quality of life, and the difficult decision-making considerations for supportive care alone. ⋯ Recommendations • Consider baseline and serial scanning with computed tomography and/or magnetic resonance (CT and/or MR) to detect recurrence in high-risk patients. (R) • Patients with head and neck cancer recurrence being considered for active curative treatment should undergo assessment by positron emission tomography combined with computed tomography (PET-CT) scan. (R) • Patients with recurrence should be assessed systematically by a team experienced in the range of management options available for recurrence including surgical salvage, re-irradiation, chemotherapy and palliative care. (R) • Management of patients with laryngeal recurrence should include input from surgeons with experience in transoral surgery and partial laryngectomy for recurrence. (G) • Expertise in transoral surgery and partial laryngectomy for recurrence should be concentrated to a few surgeons within each multidisciplinary teams. (G) • Transoral or open partial laryngectomy should be offered as definitive treatment modality for highly-selected patients with recurrent laryngeal cancer. (R) • Patients with OPC recurrence should have p16 human papilloma virus status assessed. (R) • Patients with OPC recurrence should be considered for salvage surgical treatment by an experienced team, with reconstructive expertise input. (G) • Transoral surgery appears to be an effective alternative to open surgery for the management of OPC recurrence in carefully selected patients. (R) • Consider elective selective neck dissections in patients with recurrent primaries with N0 necks, especially in advanced cases. (R) • Selective neck dissection (with preservation of nodal levels, especially level V, that are not involved by disease) in patients with nodal (N+) recurrence appears to be as effective as modified or radical neck dissections. (R) • Use salivary bypass tubes following salvage laryngectomy. (R) • Use interposition muscle-only pectoralis major or free flap for suture line reinforcement if performing primary closure following salvage laryngectomy. (R) • Use inlaid pedicled or free flap to close wound if there is tension at the anastomosis following laryngectomy. (R) • Perform secondary puncture in post chemoradiotherapy laryngectomy patients. (R) • Triple therapy with platinum, cetuximab and 5-fluorouracil (5-FU) appears to provide the best outcomes for the management of patients with recurrence who have a good performance status and are fit to receive it. If not fit, then combinations of platinum and cetuximab or platinum and 5-FU may be considered. (R) • Patients with non-resectable recurrent disease should be offered the opportunity to participate in phases I-III clinical trials of new therapeutic agents. (R) • Chemo re-irradiation appears to improve locoregional control, and may have some benefit for overall survival, at the risk of considerable acute and late toxicity. Benefit must be weighed carefully against risks, and patients must be counselled appropriately. (R) • Target volumes should be kept tight and elective nodal irradiation should be avoided. (R) • Best supportive care should be offered routinely as part of the management package of all patients with recurrent cancer even in the case of those who are being treated curatively. (R).
-
Practice Guideline
Palliative and supportive care in head and neck cancer: United Kingdom National Multidisciplinary Guidelines.
This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. It provides recommendations on the assessments and interventions for this group of patients receiving palliative and supportive care. Recommendations • Palliative and supportive care must be multidisciplinary. (G) • All core team members should have training in advanced communication skills. (G) • Palliative surgery should be considered in selected cases. (R) • Hypofractionated or short course radiotherapy should be considered for local pain control and for painful bony metastases. (R) • All palliative patients should have a functional endoscopic evaluation of swallowing (FEES) assessment of swallow to assess for risk of aspiration. (G) • Pain relief should be based on the World Health Organization pain ladder. (R) • Specialist pain management service involvement should be considered early for those with refractory pain. (G) • Constipation should be avoided by the judicious use of prophylactic laxatives and the correction of systemic causes such as dehydration, hypercalcaemia and hypothyroidism. (G) • Organic causes of confusion should be identified and corrected where appropriate, failing this, treatment with benzodiazepines or antipsychotics should be considered. (G) • Patients with symptoms suggestive of spinal metastases or metastatic cord compression must be managed in accordance with the National Institute for Health and Care Excellence guidance. (R) • Cardiopulmonary resuscitation is inappropriate in the palliative dying patient. (R) • 'Do not attempt cardiopulmonary resuscitation' orders should be completed and discussed with the patient and/or the family unless good reasons exist not to do so where appropriate. This is absolutely necessary when a patient's care is to be managed at home. (G).
-
Practice Guideline
Follow-up after treatment for head and neck cancer: United Kingdom National Multidisciplinary Guidelines.
This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. In the absence of high-level evidence base for follow-up practices, the duration and frequency are often at the discretion of local centres. By reviewing the existing literature and collating experience from varying practices across the UK, this paper provides recommendations on the work up and management of lateral skull base cancer based on the existing evidence base for this rare condition. Recommendations • Patients should be followed up to a minimum of five years with a prolonged follow-up for selected patients. (G) • Patients should be followed up at least two monthly in the first two years and three to six monthly in the subsequent years. (G) • Patients should be seen in dedicated multidisciplinary head and neck oncology clinics. (G) • Patients should be followed up by dedicated multidisciplinary clinical teams. (G) • The multidisciplinary follow-up team should include clinical nurse specialists, speech and language therapists, dietitians and other allied health professionals in the role of key workers. (G) • Clinical assessment should include adequate clinical examination including fibre-optic rigid or flexible nasopharyngolaryngoscopy. (R) • Magnetic resonance imaging and positron emission tomography combined with computed tomography imaging should be used when recurrence is suspected. (R) • Narrow band imaging can be used in the follow-up in selected sites. (R) • Second primary tumours should be part of rationale of follow-up and therefore adequate screening strategies should be used to detect them. (G) • Patients should be educated with regard to the appearance and detection of recurrences. (G) • Patients with persistent pain should be investigated to exclude recurrent disease. (R) • Patients should be offered support with tobacco and alcohol cessation services. (R).