Treatment Planning

With the above information, the patient is presented to the multi-disciplinary Head and Neck Tumor Board to obtain a consensus opinion on treatment options. In general, the oncologic efficacy of any therapy takes preference when ranking treatment options for the individual patient. The Board's recommendations can be heavily influenced by the expected post-operative functional outcome, which is significantly dependent on the reconstructive options available. Since the best reconstructive option may not be available to every patient due to expertise, previous therapy, or anatomic abnormality, functional outcome may be compromised. Especially in cases in which oncologic efficacy has a semblance of comparability, this potential functional outcome may significantly influence a patient's decision. All treatment and reconstructive options are presented to the patient. Post-therapeutic expectations should be discussed in detail. The Tumor Board's opinion frequently obviates the need for the patient to meet the radiation and medical oncology consultants, but this is certainly an option for those who would benefit during their decision process.

Efficient post-operative recovery and early inpatient discharge also involves a multi-disciplinary approach. Therapy should begin with preoperative consultation and counseling by involved surgical colleagues (i.e., neurosurgery, ophthalmology, vascular surgery, oral surgery) and anticipated ancillary personnel (i.e., speech pathology, physical therapy, social work, prostheticist) respectively. Experienced anesthesiologists understand how judicious use of intravenous fluids, vasoconstrictors, and muscle relaxants are crucial to operative success (11). Patient positioning and padding, specific vascular access placements, body temperature, oxygenation, and ventilator parameters are also important influential factors controlled by the anesthesiologist. Well-trained teams for the operating room, intensive care, and inpatient ward with prepared OR case carts, pre-printed standard orders and clinical pathways are important for a consistent and efficient hospital recovery. The presence of both the extirpative and reconstructive surgeon guiding the preparation of the operative patient can facilitate team efforts later in the operative day. In those patients who will endure a prolonged period of enteral feedings, percutaneous or open gastrostomy tube placement is prudent for maximizing preoperative nutritional status and obviating the need for a nasogastric feeding tube. This is generally more comfortable for the patient and decreases the incidence of sinusitis, gastroesophageal reflux, and pharyngeal swelling (25). All of these factors can potentially inhibit return of post-operative deglutition. The myriad of preoperative appointments is best coordinated for the patient by a dedicated patient care coordinator.

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